Corrective Action Plans

2022-004 Grant funds spent after grant period. Recommendation: The Organization should work to identify specific costs that are charged to the grant. We also recommend a review of grant funds being done prior to the end of the grant period to make sure funds can be spent prior to end of grant period. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The Organization will review the processes and implement procedures to make sure grant funds are spent prior to the end of grant period. Finance Director will provide finance committee with detail of funds spent for the grant to support amounts withdrawn for grant funds. Name(s) of the contact person(s) responsible for corrective action: Kyle Kleist Planned completion date for corrective action plan: September 30, 2023

Finding No. 2022-004: Procurement Policy ? Material Weakness in Internal Control Over Financial Reporting; U.S. Department of Health and Human Services, Rare Disorders: Research, Surveillance, Health Promotion, and Education; Assistance Listing Number 93.315 Condition There is no evidence of a documented formal procurement policy with regards to federal grant awards and expenditures, no documented support that a competitive price analysis for vendors and organizations funded with federal grant funds were performed and no evidence that suspension and debarment verifications were performed for certain vendors and organizations, as required by the general procurement standards of the Uniform Guidance. Recommendation It was recommended that the Association establish a written procurement policy governing contracts with vendors that will be reimbursed by federal grants to incorporate all of the provisions included in the general procurement standards of the Uniform Guidance Section 200.318 and the debarment and suspension regulations of Uniform Guidance Section 200.214. It was also recommended that a review of all existing vendor or sub-awardee contract files be performed to ensure that the documentation as required under the Uniform Guidance is maintained in the files. Action Taken The Spina Bifida Association will take action to ensure an up-to-date Procurement Policy is approved by the Board of Directors. Anticipated Completion Date December 2023

Finding 2022-001: Management followed the HRSA uninsured patient reimbursement program guidelines and frequently asked questions (FAQs) related to diagnostic testing and testing-related visits eligible for reimbursement, which were published from time to time after the introduction of this program. One such FAQ that management referred to and followed is shown below. We did not separate out and only submit specific COVID-19 diagnoses codes but we sent the entire charges relating to the patient to Health Resource & Services Administration (HRSA) if it had testing or treatment services provided related to COVID-19. Management?s understanding was that HRSA would determine what charges would be eligible for reimbursement so long as the claims that were submitted included treatment or testing services for uninsured patients related to COVID-19. These payments were approved and paid for by HRSA as they included the eligible diagnosis codes and hence management deemed this to be appropriate. However, management does agree with the finding that the questioned costs were incorrectly paid by HRSA. Management has submitted a refund for the portion of these claims payments that were unrelated to COVID?19 treatments. Prime Healthcare Foundation, Inc. hospitals perform eligibility checks and input insurance coverage details as a mandatory information gathering requirement during the admission of a patient. Prime Hospitals performed these eligibility checks for all patients by examining online insurance portals, interviewing patients and obtaining self-declaration of insurance status from patient upon patient admission. However, there were instances when hospitals did not retain insurance eligibility documentations although it was performed, for reasons such as emergency and urgency of patient care. Although this documentation was not in the file for these patients, all audit samples selected were ultimately shown to not have insurance coverage at the time services were rendered. Management agrees with the finding on lack of documentation retention for patient eligibility checks and will implement this as a facility control. Contact person: Kenneth Wheeler, Regional Vice President, Sowkya Ponnavolu, Corporate Director of Data Engineering & Analytics and Merhawy Worede, Corporate Executive Director of Accounting and Financial Reporting. Expected completion date: Management has submitted the questioned costs for refund to HRSA. Regarding the eligibility checks, according to HRSA COVID-19 Uninsured Programs Claims Submission Deadline FAQs published in April 2022, the COVID-19 Uninsured program stopped accepting claims and funding on April 5, 2022 and thus there are no changes required related to this particular program. However, if this program begins accepting claims again, management will implement a control requiring retention in the patient files supporting that the required eligibility checks have been performed.

Views of Responsible Officials and Planned Corrective Action: The Organization will be more diligent in identifying and reporting Federal Awards.

Finding Reference Number: 2022-001 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. Management agrees with the finding. Management repaid the funds on June 10, 2022. Completion Date: June 10, 2022

Finding Reference Number: 2022-002 Concur or Do Not Concur: Concur Agree or Disagree with Auditor Recommendations: Agree Actions Taken or Planned on the Finding: Management agrees with the finding. The funds were deposited back into the restricted account on June 24, 2022. Completion Date: June 24, 2022

MATERIAL WEAKNESS IN INTERNAL CONTROL OVER COMPLIANCE AND MATERIAL NONCOMPLIANCE ? U.S. DEPARTMENT OF EDUCATION, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION, TITLE I GRANTS TO LOCAL EDUCATIONAL AGENCIES ? FEDERAL ALN 84.010 2022-003 Internal Control Over Compliance and Noncompliance With Federal Allowable Cost Requirements Finding Summary 2 CFR ? 200.430 (i) requires Independent School District No. 624 (the District) to maintain records that adequately and accurately identify the source and application of funds for federally-funded activities in accordance with 2 CFR 200 Subpart E ? Cost Principles. The District did not have sufficient controls to ensure proper determination of allowable costs charged to the Title I program, which resulted in reportable instances of noncompliance. Corrective Action Plan Actions Planned ? The District has reviewed policies and procedures relating to allowable costs for all federal programs and implemented an additional procedure to compare actual time and effort documentation to the costs allocated to each federal program and adjust as necessary at year-end, to ensure compliance with the Uniform Guidance in the future. Official Responsible ? The District?s Director of Teaching and Learning, Jennifer Babiash. Planned Completion Date ? June 30, 2023. Disagreement With or Explanation of Finding ? The District agrees with this finding. Plan to Monitor ? The District?s Director of Teaching and Learning, Jennifer Babiash, will assure appropriate internal controls and procedures are updated and in place to ensure compliance with allowable cost requirements for future federal awards expenditures.

CORRECTIVE ACTION PLAN JANUARY 10, 2023 The Brevard Health Alliance, Inc. respectfully submits the following corrective action plan for the year ended September 30, 2022. Name and address of independent public accounting firm: Carr, Riggs, and Ingram, LLC 215 Baytree Drive Melbourne, FL 32940 Audit Period: Fiscal Year October 1, 2021 - September 30, 2022 The finding from the January 10, 2023 schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the number assigned in the schedule. 2022-001 PROCUREMENT PROCEDURES COVID-19 Health Center Program (Community Health Centers, Migrant Health Centers, Health Care For Homeless and Public Housing Primary Care) ? American Rescue Plan Act Assistance Listing Number: 93.224, Contract Numbers- H8F41284 Department of Health and Human Services (HHS) 2022 Funding Pursuant to 2 CFR ?200.1, Simplified Acquisition Threshold (?SAT?), acquisitions which exceed the SAT of $250,000 must use one of the following procurement methods: the sealed bid method, the competitive proposals method, or the noncompetitive proposal method (sole source). The Alliance did not utilize the sealed bid method or competitive proposals method for a purchase of computer hardware, which exceeded the $250,000 SAT. The Alliance?s procurement policy was not updated to be in compliance 2 CFR 200.1 until April 2022. This purchase began in fiscal year 2021, but the remaining items under the contract were procured in fiscal year 2022. Perspective: The purchase made at the beginning of the year was procured under the old purchasing policy. The policy was updated in April 2022, and the additional purchase exceeding the bid threshold made subsequent to the new purchasing policy was procured under a competitive process. Recommendation: The Alliance should continue to follow its updated procurement policy. Responsible Party: Shannon Wherry, Controller Corrective Action: Management updated the procurement policy April 2022 to comply with the provisions of 2 CFR ?200.1, 2 CFR ?200.67, and 2 CFR ?200.214. The updated policy has been implemented since this occurrence and will continue to be followed.

Finding 2022-001 - Controls Over Cash Management (Significant Deficiency) Criteria: According to Title 2 U.S. Code of Federal Regulations (" CFR") Part 200 , paragraph 305, non-federal entities are required to minimize the time that elapses between the transfer of funds from the federal funding source and the disbursement of those funds by the non-federal entity for the program's intended purposes. Condition and Context: As a part of our testing over cash management of funds received from the federal funding source, we examined information showing the dates on which five program-related disbursement of federal funds were received by the Corporation , and we compared those dates to the dates when the Corporation remitted the amounts for the purposes of covering payroll expenses and paying its various contractors. We noted one draw for $1,184,367 that was received from the federal funding source with no payments made to the contractors for which the funds had been appropriated. This resulted in a period of 16 days between receipt of the federal funds and the corresponding payments to the contractors. We also noted one of the five draws tested were for an incorrect amount. The Corporation submitted a draw for $29,997 in error. The overdrawn funds were repaid to the federal funding source. The Corporation prepared a schedule of draws made during 2022 and it was noted that the Corporation drew or repaid an incorrect amount in four months of the year, of which some were corrected in the next period. Effect: As a result of these matters , the Corporation essentially borrowed money from the federal government and potentially delayed payment to vendors. Cause: The condition was caused by an oversight by management that resulted in invoices not being processed for payment unt i l well after the cash had been drawn by the Corporation and resulted in draws to processed for an incorrect amount. Questioned Costs: From our sample tests , the Corporation overdrew $29,997 for the month of May 2022. Recommendation : We recommend that management designate a specific individual to be responsible for monitoring the receipt of federal funds on a daily basis . This person should be tasked with ensuring that funds that have been transferred from the federal funding source are disbursed to the intended contractors within a short period following receipt of these funds and ensuring that the correct draw amounts are submitted. We also in compliance with Federal statutes, regulations and terms and conditions of the Federal award. The Corporation should have controls in place to document that salaries and overtime paid with federal funds were allowable. Timecards supporting hours worked should be approved and pay rates reviewed. Condition and Context: A summary of allowable charges for the grant was prepared for submission. Differences were noted when comparing the summary to timecards. Within the sample of 45, we noted that 31 timecards did not have a documented review. From the sample, we noted that the pay advice form, which reflects pay rate changes, for 2 employees did not indicate signature by an approver and only indicated the requestor's signature. The employees' new pay rate as indicated on the pay advice form was reflected in the payroll expenditure. Additionally, within the sample of 45, we noted 1 employee that did not have a pay advice form or contract to support the pay rate. We noted the following control items: ? 31 out of 45 timecards tested did not have documented review. ? 2 out of 45 employees tested did not have pay advice forms signed by both the requestor and reviewer. Only the requestor signed the form. ? 1 out of 45 employees tested did not have a pay advice form or other supporting documentation for the pay rate. Effect: Payroll expenditures could be inaccurately charged to the federal grant. Cause: The lack of documented timecard and pay rate approval were an oversight. Questioned Costs: None Recommendation: We recommend the Corporation maintain documented approval of all timecards and pay rate increases. Views of Responsible Officials and Planned Corrective Actions: The Transportation Department provides a spreadsheet that details time operators work by route. This process is used to align FTA funding streams with routes driven. The spreadsheet is kept by the Transportation Manager and reviewed by the Director of Transportation. These two positions approve time prior to submitting it for processing. GPTC is engaging its current payroll provider to assist in finding a technological solution to capturing start and end times of each operator. Until we can get this technical solution, an approval form will be submitted by the Transportation Department along with the allocation spreadsheet. As stated above, GPTC experienced a lot of turnover and personnel changes - the Human Resource Department had many. Pay advices are managed by this department. Our recommend that management prepare a schedule of all claims to determine whether there are additional amounts that have been overclaimed. Views of Responsible Officials and Planned Corrective Actions: In 2022, GPTC experienced a lot of turnover and personnel changes in multiple areas. In reassigning responsibilities, the Finance Department was designated as the area to handle FTA fund requests in June 2023. Absorption of these responsibilities required them to get an understanding of the process, formulate procedures for drawdowns, and develop a method for monitoring these dollars. The first drawdowns by the new team occurred in August 2023. FTA dollars are a major source of funding, so managing this process is highly important. GPTC has implemented a review process, as required by the FTA; and developed a spreadsheet for formulating amounts to be drawn. Iniquities in the spreadsheet were remedied in September 2023, and future processing has been good. GPTC realizes that FTA grants are reimbursable. The process requires prepayment of expenses, proof of payment, and reclamation of the FTA's portion of expended funds. So, future funds will be disbursed in a timely fashion. Large dollar amounts that require FTA funding for payment will be disbursed within three days, as required.

See corrective action plan

See corrective action plan

The contractor, Johnson Control provided information that they are a unionized operation and the use the union wages scale that exceeds prevailing wages. We will in the future ensure that any contractor that we used over $2,000.00 will have a formal contract that includes the David-Bacon Act.

Program: Low Rent Public Housing AL Number: 14.850 Finding Number: 2022-001 Audit Finding (Copied & Pasted Directly from Auditor?s Report): Condition: During our audit, the Authority transferred PHA cash and charged asset management fees in AMP 2 and AMP 3 in excess of the excess cash amount from the 2021 audited numbers. Context: AMP 4 and AMP 10 have issues cash flowing and rely on the other AMPS to transfer excess cash every year. In 2021, the other AMPs had less excess cash, so were unable to subsidize AMP 4 and AMP 10 like normal. The Authority did not detect the cash flow issue until after the fiscal year ended. Resulting in noncompliance with the program's rules Cause: Controls were not followed to ensure fungibility rules between each project were followed Criteria: After subsidy (operating) is calculated at a project level, operating subsidy can be transferred as the PHA determines during the PHA's fiscal year to another ACC project(s) if a project's financial information, as described more fully in 240 CFR ? 990.280, produces excess cash flow, and only in the amount up to those excess cash flows. 240 CFR ? 990.205. Corrective Action to Be Taken: Executive Director, Holly Girdwood, is responsible to train/teach the Comptroller, Tara Sheffler, to perform monthly reconciliations to ensure fungibility is properly maintained. This should be completed prior to year-end December 31, 2023. In response to the context, it was our understanding that we could charge asset management fees to all AMPS due to COVID guidelines. Contact Responsible for Corrective Action: Tara Sheffler Comptroller PO Box 988 481 Neshannock Avenue New Castle, PA 16103 724-656-5100 ext. 5100 tsheffler@lawrencecountyha.com

Recommendation: Training of staff should be performed to bring the staff up to date with the implementation of all residual receipts compliance requirements. Action Taken: The Organization will request approval from HUD to pay back the excess residual receipt balance.

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Prosser School District No. 116 September 1, 2021 through August 31, 2022 This schedule presents the corrective action the District is planning to take for findings included in this report in accordance with Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Finding ref number: 2022-001 Finding caption: The District did not have adequate internal controls for ensuring compliance with allowable activities and costs and restricted purpose requirements. Name, address, and telephone of District contact person: Amy Hill, Business Manager, 1500 Grant Avenue, Prosser, WA 99350 (509) 786-3323 Corrective action the auditee plans to take in response to the finding: Although the District does not concur with the audit finding, we will take the following corrective steps: 1) Add questions for the student/staff member at the time of device distribution to determine ?unmet need? 2) Document the response 3) Retain the response for the required retention period Given the timing, the District will not be able to implement these changes for the 2022-2023 cycle, so the earliest date of implementation would be the 2023-2024 school year. Anticipated date to complete the corrective action: 9/1/2023

Finding # 2022-007 Title of Finding Subrecipient Monitoring Contact Person Brook Hinzman Anticipated Completion Date June 2023 Corrective Action planned to be taken: Will comply and monitor subrecipient spending going forward.

PLANNED CORRECTIVE ACTIONS: ? CORRECT YEAR-END SPREADSHEET RECONCILIATIONS TO ENSURE PROPER MONITORING ? CONTACT PENNSYLVANIA DEPARTMENT OF EDUCATION TO RECTIFY THE OVERPAYMENT ? CONDUCT REGULAR REVIEW OF ORIGINAL GRANT BUDGETS AND ANY CORRESPONDING REVISIONS WITH MULTIPLE STAFF MEMBERS TO ENSURE THAT NO ERRORS EXIST

Finding: 2022-6 Name of contact person: Dyani Lynch, Supervisor Crisis & Medicaid Transportation Dept. Corrective Action: The Crisis Department will do a monthly review of Crisis and LIEAP policies to stay on top of any changes that may occur between fiscal years and to ensure we are implementing correct procedures. We will also perform self-audits monthly. We will randomly pull two applications from each caseworker to ensure that we are improving on where we?ve made errors and that we are correctly documenting/processing applications. Based on any findings/questions we have during these self-audits, we will contact our state representative for clarifications. Proposed Completion Date: March 31, 2023

Finding: 2022-4 Name of contact person: Renae Alston Corrective Action: The County will continue to train employees on a monthly basis and as needed when new and updated policies are received. Supervisors and lead workers will continue to conduct second party reviews and utilizing any findings to aid in training staff on any necessary policy information. The County added a Quality Control position effective January 1, 2021 to assist with conducting second party reviews and training. During Fiscal Year 2021 an experienced supervisor was hired for adult Medicaid with extensive knowledge of long-term care and SA policy. This has led to internal process changes for the department. The department will continue to implement changes as necessary to achieve the overall improvement of eligibility determinations. Proposed Completion Date: June 30, 2023

Name of auditee: Bandera Senior Housing Corp. HUD auditee identification number: 122-EE112 Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended September 30, 2022 CAP prepared by Name: Mary Grace Crisostomo Position: Asset Manager Telephone number: (925) 924-7102 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Finding 2022-001: Comments on the Finding and Each Recommendation During the year ended September 30, 2022, management made duplicate withdrawals from the reserve for replacements account totaling $14,720. The reserve for replacements account was not reimbursed for these duplicate withdrawals. Management should transfer funds of $14,720 from the operating cash account to the reserve for replacements account. Action(s) taken or planned on the finding Management concurs with the finding and the auditor's recommendation. Management intends to transfer $14,720 from the operating cash account to the reserve for replacements account.

SINGLE AUDIT FINDINGS: Finding 2022-001: Procurement and Suspension and Debarment Description of Finding: During our testing, the Board of Education did not retain supporting documentation of required quotes for small purchases in accordance with UG for two of the seven vendors sampled. Statement of Concurrence or Nonconcurrence: There is no disagreement with the audit finding. Corrective Action: The Board of Education follow the revised procurement policy effective January 1, 2022, and provide supporting documentation for all sole source vendor transactions. Name of Contact Person: Todd Bendtsen, Business Manager Projected Completion Date: June 30, 2023

Views of Responsible Officials and Planned Corrective Actions Management agrees with the finding and will implement the auditor?s recommendations. The recommendation, if effectively implemented, should prevent this condition from arising again. Action 1- The issue was communicated to the management company and the property was reimbursed for $2,450 on September 26th, 2023. Action 2-To prevent a future overpayment of the management fee, a procedure will be implemented whereby the management fee will be recalculated using the rate included in the current management certification. Any differences will be investigated and resolved before the management fee is paid to the management company.

Views of Responsible Officials and Planned Corrective Actions Management agrees with the finding and will verify the eligibility of the assistance payments that could not be located. We will also continue to self-audit payments to ensure program eligibility.

Contact Name: Becky Blair, CFO Contact Phone Number: 870-448-5733 Audit Period Ending: December 31, 2022 Audit Firm: FORVIS, LLP Federal Program: Provider Relief Fund (PRF) and American Rescue Plan (ARP) Rural Distribution, Assistance Listing No. 93.498 Federal Agency: U.S. Department of Health and Human Services Payment Received Period: Period 4, July 1, 2021 to December 31, 2021 Finding Number: 2022-001 Statement Condition: The Organization incorrectly reported all period four provider relief payments were applied to unreimbursed expenses attributable to COVID-19 within the HHS Provider Relief Fund (PRF) portal. Total expenditures reported had not been incurred by the Organization. Response: Management concurs with the finding and recommendation and will implement controls to ensure all reporting is reviewed for accuracy.

Reference Number: 2022-003 Federal Agency: U.S. Department of Housing and Urban Development Federal Program Title: Section 8 Housing Choice Vouchers Federal Catalog Number: 14.871 Federal Grant Number: Not Applicable Category of Finding: Special Tests and Provisions (Housing Quality Standards Inspections) Classification of Finding: Material Weakness in Internal Control over Compliance Material Noncompliance Authority?s Response & Actions Taken The Authority has made considerable progress in addressing the backlog of annual inspections. Since outsourcing the programmatic functions of the HCV program to a third-party contractor. The Authority acknowledges that more progress in this area is required and continues to work diligently with the third-party HCV contractor to ensure this occurs. The Authority will continue to reinforce its current oversight process to ensure HQS inspections are performed in accordance with HUD requirements. The Authority adopted a series of HUD waivers following the COVID-19 pandemic, one of which HQS-5, under Notice PIH 2021-14, allowing the Authority to waive the completion of HQS Inspections through December 31, 2021. The Authority resumed the completion of HQS Inspections and was required by HUD to complete all delayed inspections by December 31, 2022. During fiscal year 2022, the Authority had inspections not completed in a timely manner, however, was not out of compliance as waivers were in place. The Authority is committed to ensuring all units under contract are beyond safe, sanitary, and decent in accordance with HQS requirements and the Authority's Administrative Plan. The Authority uses the Emphasys Elite software to check against HUD's PIH Information Center (PIC) system to identify units with outstanding Housing Quality Standards (HQS) Inspections. The Authority has scheduled HQS Inspections for the units identified to be out of compliance. Some key strategies and controls in place are as follows: ? Review the report of outstanding HQS Inspections on a weekly basis. ? Schedule outstanding HQS Inspections in order of aging date. ? Conduct HQS Inspections prior to anniversary date of previously completed inspection. ? Running a monthly report of failed inspections and comparing them with future scheduled inspections to ensure a timely scheduling of the second inspection. ? Running a monthly report to identify units with two failed inspections to ensure all have been abated correctly. ? Implement weekly monitoring to ensure all units are properly abated and lifted timely when units pass inspections and contracts are properly terminated after being in abatement for 180 days without a cure. The Authority will continue to execute these sound procedures to prevent further findings related to inspections. The Authority has implemented a robust internal audit program starting fiscal year 2021- 22 and will continue to select annually a statistically significant random sample of actions completed by the HCV contractor to ensure that all actions are in compliance and files contain all required documentation. Although the HCV program subscribes to a quality control process, the Authority's internal audit program provides a method to reasonably understand the condition of the program as the Authority fully understands its responsibility to ensure the program complies to all applicable laws and regulations governing HCV operations. The HCV program is a part of our continuous monitoring process. Anticipated Implementation Date September 30, 2023 Name(s) and Title(s) of Contact Person(s) Responsible for Correction Action HCV Contractor Kendra Crawford, Director of Housing Operations