Corrective Action Plans

Finding 2022-004 Improve Time and Effort Documentation Planned Corrective Action: The Housing and Economic Development Department will establish a process to document time and effort certifications for salaried employees, and ensure that compliance is monitored on an ongoing basis by the HCD Division Director. Anticipated Completion Date: May 1, 2023 Contact Person: Mary Davis, Interim Department Director, Housing and Economic Development and Division Director, Housing and Community Development

2022-003 ? Procurement Auditee?s Response and Planned Corrective Action JCHA will implement and follow a procurement policy that follows HUD procurement regulations. In addition, the Authority will receive training to better understand HUD?s procurement requirements. Planned Implementation Date of Corrective Action: On or by June 30, 2023. Person Responsible for Corrective Action: Any staff with procurement authority.

Finding Number: 2022-002 Condition: We examined $1,746,599 of federal funds reimbursed to the City from the State Revolving Fund award during the year. Management informed us and we verified that $134,102 of reimbursements were for ineligible construction costs as these amounts were bid alternates that were not allowed uses of the federal award. Further, management informed us and we verified that $17,253 of federal reimbursements were received for a duplicate construction invoice. Further, as a result of reviewing the ineligible costs, management found that in fiscal year 2021, ALN 66.458 included $5,768 in ineligible expenditures, and the overall total expenditures was understated by $184,073. In addition, ALN 14.228 had expenditures of $229,554 that were understated in fiscal year 2021, and ALN 10.760 had expenditures totaling $81,228 that were understated in fiscal year 2021. Planned Corrective Action: The City adopted an allowable cost policy on 04/17/23. Contact person responsible for corrective action: Kathryn Beemer, City Administrator Email: kbeemer@fennville.com Office Phone: 269-561-8321 Cell Phone: 269-543-2645 Anticipated Completion Date: 04/17/23

Finding Reference Number: 2022-1 Condition: Beaumont Elderly and Handicapped Housing Corporation overpaid its management fee in the amount of $6,300 as of March 31, 2022. View of Responsible Officials and Corrective Actions: Management concurs with the finding and reimbursed Beaumont Elderly and Handicapped Housing Corporation for the overpaid management fee amount on May 19, 2022. Contact Person Responsible: Darren Ryan, Controller Completion Date: May 19, 2022.

U.S. Department of Education 2022-002 21st Century Community Learning Centers ? Assistance Listing No. 84.287C Recommendation: We recommend the Organization design controls to ensure an adequate review process is in place to review amounts charged to the grant prior to submitting for reimbursement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: A new Chief Financial Officer was hired in March 2022 with appropriate expertise to evaluate financial reporting processes and controls. Additional controls over the preparation of financial statements to provide reasonable assurance that financial statements are prepared in accordance with U.S. GAAP have been implemented.. Name(s) of the contact person(s) responsible for corrective action: Jerri Kautsky Planned completion date for corrective action plan: completed as of date of audit report, December 8, 2022. If the U.S. Department of Education has questions regarding this plan, please call Jerri Kautsky, CFO, at 239-255-7223.

U. S. Department of Housing and Urban Development (Pass-through from Virginia Office of Community Planning and Development) Assistance Listing #14.267 Finding: 2022-003 Known Questioned Costs for a Federal Program Not Audited as a Major Program Criteria: In accordance with 2 CFR 200.516(a)(4) known questioned costs that are greater than $25,000 for a program that is not audited as a major program must be reported as an audit finding in the federal awards section of the schedule of findings and questioned costs. In September 2022, the U. S. Department of Housing and Urban Development, identified $1,463 of unallowed expenditures and a deficit of $27,464 in the required cash match under the Continuum of Care program for the year ended December 31, 2021, as a result of monitoring. Rapid Rehousing Requirements: Criteria: 24 CFR 578.51; 24 CFR 578.57 Condition: The Federal awarding agency has determined, in accordance with 24 CFR 578.51; 24 CFR 578.57; $1,463 of allowable HMIS expenses were not documented and that in accordance with 2 CFR 200.1; 2 CFR 200.103(a)(11); 2 CFR 200.306; 24 CFR 578.73 the grantee failed to match $27,464 on its Continuum of Care rapid rehousing project. Corrective Action Plan: The CFO will ensure that the HMIS expenses are being captured in financial documents be setting up a new account code in the financial software. Staff members that have HMIS hours will also record those hours separately on their timesheets each pay period. NRCA will be submitting copies of timesheets which record data entry by line item as further documentation of the HMIS expenses submitted in answers to the monitoring report. While NRCA respects the position of the Department of HUD, NRCA also believes management followed the grant agreement as submitted. NRCA sees resolution to this matter with the Department of HUD and is currently seeking counsel to ensure this resolution in an acceptable and appropriate manner. Persons Responsible: Michelle Cox, Chief Financial Officer and Krystal Thompson, Chief Executive Officer Timing for Implementation: Immediate

Finding 2022-001 Condition The Company did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. The Company excluded from patient care revenue the amount attributable to independent living and assisted living related services provided to residents. Additionally, the report did not contain a documented review and approval of the reports prior to submission. Clerical errors were identified during testing totaling $25,179 and expenses were counted twice in error totaling $38,423 Corrective Action Plan Corrective Action Planned: The Company agrees with the finding. It is believed that verifiable lost revenues were more than sufficient to fully cover the funds received even eliminating these expenditures. Nonetheless, if any additional similar funding is ever sought or received, the Company will implement policies and procedures to ensure there is appropriate review of the submissions and lost revenue calculations. The Company agrees with the finding and will implement procedures to ensure an individual who is responsible for reporting will remain current on compliance requirements and review final reports and the related inputs prior to submission. Specifically, the Company will verify independent living unit revenues are included in the lost revenues? calculation. Name(s) of Contact Person(s) Responsible for Corrective Action: Daniel Murray, CEO and Timothy McQuaid, CFO Anticipated Completion Date: completed

Respectfully, the school corporation does not agree with several of the findings in regards to segregation of duties and purchases. First, the SBOA auditors' told the school corporation during the 2019 audit that operating the school lunch program through the extracurricular account was not legal. The school corporation was informed that this account must be transferred to Central Office and a Corrective Action Plan must be in place. This directive was incorrect and pointed out in the official response from November 5, 2019 under IC 20-26-5-4(a)(l l). Second, segregation of duties, oversight, and approval of functions existed in 2019 and are presently occurring daily, weekly, and monthly within the cafeteria program under the corporation accounts and supervision of Central Office. Cafeteria workers record and submit timesheets of duties performed during each payroll period. The Cafeteria Director verifies and signs timesheets to be submitted to the Treasurer and Deputy Treasurer for review and payment from the Cafeteria account. A payroll docket report is sent to the Superintendent prior to payment from the bank. Prior to the 2019 audit, the High School Treasurer spent approximately two hours per day counting cash received each day from school lunches purchased. She also receipted those funds it into the software system, made deposits to the bank, paid invoices for food expenses, and processed part of payroll. Tasks conducted by the High School Treasurer were segregated by a timesheet and supervised by the High School Principal. All those tasks were shifted to Central Office in 2020 and are now segregated to the Treasurer and Deputy Treasurer. The Treasurer documents hours spent on Cafeteria accounts on a timesheet for review and signature by the Superintendent. Financial reports of expenditures and revenues are provided for review and oversight to the Superintendent and School Board at monthly board meetings. Third, RSSC has a small Central Office consisting of a Superintendent, Treasurer, Deputy Treasurer, and Secretary. It has no Assistant Superintendents, Human Resources Director, or Business Manager. Each person in Central Office wears multiple hats and performs multiple duties each day. It was noted in the Audit Report filed from July 1, 2008 to June 30, 2010 that " ...Randolph Southern School Corporation is unable, due to financial limitations, to employ additional personnel to segregate duties in our receipts and cash and investment balances. This statement would apply to all of our internal controls. " The circumstances for RSSC have not changed in the audit periods from July 1, 2010 through June 30, 2022. Corrective Action Plan: The School Board had chosen not to add additional staffing due to costs. RSSC is still unable to segregate duties for financial transactions and reporting. Fourth, the Cafeteria Program only has one full-time staff member, the Cafeteria Director. Eight part-time cafeteria workers prepare and feed up to 300 students each day. This food service program is one of the best run programs in the State oflndiana. It has not had one food preparation or sanitation violation from IDOE or Department of Health in the last 12 years. Fifth, the Cafeteria Program is economically efficient and fiscally responsible. The account carries at least a 3-month cash balance at all times. This success is a direct result of oversight by the combination of the Superintendent, Treasurer, and Cafeteria Director. RSSC adopted board policy 6114 Cost Principles-Spending Federal Funds on May 9, 2016. RSSC has had an Indirect Cost Rate in place since 2013. The adopted policy allows the school corporation to apply Indirect Costs to all federal funds including the Cafeteria account. On December 5, 2019, email communications between the Dr. Donnie Bowsman, Superintendent and Tina Herzog, IDOE Assistant Director of Operations and Food Distributions clearly state the school corporation can apply the Indirect Cost Rate to the Cafeteria account. The email communication clearly states that the high cash balance was a result of not applying the Indirect Cost Rate to the Cafeteria account (See Exhibit 1 Emails). The Indirect Rate was approved by the IDOE Office of School Finance and existed prior to the audit years being referenced in the finding. Technically, the prospective portion (going forward for the next school year) as referenced on pages 24-25 of USDA Indirect Cost Guidance Manual pertains to the 2013 Fiscal Year. Moreover, the fact was reiterated by the IDOE School Nutrition Office with email communications on December 5, 2019, not 2021 or 2022 as referenced in the finding. RSSC has not charged or recouped the Cafeteria Account the Indirect Cost rate for many years and has subsidized this account which should be independent and self-sufficient. The School Corporation did not apply the Indirect Cost Rate in 2020 or 2021 because we were not sure how many students would be eating and how fiscally sound the account would be due to students not attending school because of COVID. Corrective Action Plan: The Indirect Cost Rate will be applied and collected in the future prior to June 30 of each current fiscal year. It should also be noted that in 2021, RSSC purchased a new cafeteria dishwasher utilizing ESSER II funds. This unit was 20+ years old and needed to be replaced in order to continue feeding children and to run the food service program. This expense could have been and should have been a direct cost of $58,189 to the Cafeteria account. However, due to the unknown circumstances of COVID, the RSSC could not take a chance. The ESSER II grant is still open and we are now questioning whether this expense could be charged directly to the Cafeteria account. Those ESSER II fund could be utilized for staffing to support student learning loss and remediation. Sixth, COVID caused this financial account to increase exponentially from 2020 to 2021. ESSER funds were provided by the federal government to provide free lunches to every child which paid the food operations expenses for two school years. Student participation of eating school lunches increased during these time periods. Additionally, staff members were receiving hazard pay incentives on top of their regular hourly rate. Further, the School Corporation and Cafeteria Program took on the enormous task of feeding children over the summers of 2020 and 2021 when COVID cases were at its peak. The cafeteria personnel fed 5286 and 5740 students respectfully during those summers. The number of meals served during the summer almost equaled the total amount of meals served during the entire school year for each respective academic year. These additional meals created additional unexpected revenues for the fiscal year. The school corporation did not charge mileage for satellite lunches being delivered or indirect costs.

See corrective action plan for chart/table.

Finding # 2022-003 Significant deficiency over financial reporting Significant deficiency/immaterial noncompliance over federal awards U.S. Department of the Treasury 21.027 Coronavirus State and Local Recovery Funds Finding: Expenses were charged to the contract which related to future periods. Recommendation: There should be reconciliations and oversight of contract billings and accounting records to ensure activity is charged and recorded according to contract requirements and U.S. generally accepted accounting principles. Corrective Action: We are reviewing invoices to ensure all expenses are recorded in the proper period. Anticipated Completion Date June 30, 2023

Finding # 2022-005 Significant deficiency/immaterial noncompliance over federal awards U.S. Department of the Treasury 21.019 Coronavirus Relief Fund 21.027 Coronavirus State and Local Relief Funds Finding: Amounts charged to the contract were unallowable. Recommendation: Procedures should be implemented to provide oversight of contract billings and accounting records to ensure activity is charged and recorded according to contract requirements. Corrective Action: We will provide additional training to staff on proper expense charges as well as review invoices to ensure all expenses are allowable before requesting reimbursement. Anticipated Completion Date December 31, 2023

Finding Reference Number 2022-2 S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that they did not pay the debt in full at maturity. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2022 S3800-150 Response The Corporation is working with HUD and a local developer to resolve the outstanding loan balance. S3800-160 Contact Person First Name Amin S3800-180 Contact Person Last Name Akbar

Finding Reference Number 2022-1 S3800-090 Auditor's Summary of the Auditee's Comments on the Finding and Recommendations The Corporation concurs that they did not pay the debt in full at maturity. S3800-130 Response Indicator Agree S3800-140 Completion Date April 30, 2022 S3800-150 Response The Corporation is working with HUD and a local developer to resolve the outstanding loan balance. S3800-160 Contact Person First Name Amin S3800-180 Contact Person Last Name Akbar

View of Responsible Official(s) and Planned Corrective Action: The Commission agrees that the finding identified by UHY occurred. Specifically, the Commission requested reimbursement of $33,494 of expenses prior to the period of performance start date of the award. The Commission has since remedied this finding by paying back the federal awarding agency in February 2023 for the amount and utilizing another federal grant to charge the expenses to. In the future, the review of grant reimbursement requests will explicitly include consideration that the expenses charged to an award are within the period of performance by documenting said period on the requests approval form.

During the COVID-19 pandemic, DCH Health System (DCH) developed a methodology to identify eligible costs in accordance with the Health and Human Services (HHS) produced COVID-19 Provider Relief Fund (PRF) Reporting Requirements and FAQ guidance. DCH's methodology identified costs used to prevent, prepare for, and respond to coronavirus that fell into the following categories: COVID-19 specific costs, direct and indirect incremental costs due to COVID-19, and calculated lost revenue. To calculate direct and indirect incremental costs due to COVlD-19 for DCH Regional Medical Center, DCH leveraged HHS FAQ guidance from October 28, 2020, that introduced examples demonstrating how providers could calculate marginally increased expenses related to coronavirus using a reasonable methodology comparing pre-pandemic to post-pandemic average expenses for an office visit. OCH utilized this methodology to calculate direct and indirect incremental costs due to COVID-19 on a per-patient discharge basis, which is akin to an office visit for a hospital, per the HHS FAQ guidance. Though this specific example was removed in subsequent versions of the FAQ, HHS never communicated that the guidance that DCH relied upon to calculate incremental expenses was incorrect. DCH's view is that the total cost of patient discharge includes direct patient care and indirect costs (overhead and general administrative (G&A) costs). Indirect costs (e.g., facilities, maintenance, utilities, and management salaries) were incurred by DCH to prepare, prevent, and respond to COVID-19, consistent with the intention of the purpose of the PRF to 'provide financial support to providers who experienced lost revenues and increased expenses during the pandemic in order to maintain national health system capacity.' For instance, the ability to serve COVID-19 patients relied on incurring utility expenses to keep ventilators and other equipment functioning, of which the organization utilized well more than the norm which resulted in higher utility costs. These costs were vital for accommodating COVID-19 patients during the pandemic, just as they were necessary for serving other patient types before the onset of COVID-19. These incremental indirect costs were also not reimbursed through other sources. DCH allocated indirect costs in accordance with other accepted government rules as defined in various government regulations such as 2 CFR and the Federal Acquisition Regulation. The indirect costs allocated to patient care costs were considered part of the total cost of patient discharge. In addition, though DCH calculated lost revenue, DCH did not report on lost revenue as part of the system's use of funds (please note that there was one reporting period where Fayette had to report separate from DCH because of targeted funds received. Fayette did report lost revenue in that period based on a budget to actual calculation). DCH believes that the funds identified and reported are consistent with HHS guidance and the spirit of the law to maintain national health system capacity It is DCH's understanding that Single Audit Finding 2022-001 is particularly focused on DCH's approach to identifying indirect incremental costs due to COVID-19, citing these expenses as ineligible costs that were included in the HHS PRF portal submission. Similarly, DCH did not report lost revenues, resulting in 'inaccurate lost revenues reported.' Both FORVIS and DCH acknowledge that DCH incurred eligible expenses and lost revenue sufficient to cover the PRF funds received. Therefore, based on the FORVIS finding, and assuming the finding is sustained, DCH will implement processes to submit future PRF reports as suggested in Single Audit Finding 2022- 001, which includes identifying specific individual expenses incurred during the reporting period to prevent, prepare for, and respond to COVID-19, rather than utilizing the initial HHS guidance for calculating incremental costs due to COVID-19. In addition, OCH will include lost revenue in the PRF portal submission.

2022-004 Weaknesses in controls surrounding accounting for federal grants. A. Name of contact person responsible for corrective action: Name: Michelle Cage Title: Chief Financial Officer B. Corrective action planned: The business manager will strengthen controls to ensure the district does not request funds until they have been expended. C. Anticipated completion date: June 30, 2023

View of Responsible Officials and Planned Corrective Action: The Authority has recognized the deficiencies in the Housing Voucher Cluster Programs and will implement internal control procedures that will ensure compliance of federal regulations. Dr. William F. Myles will be responsible to implement this corrective action by September 30, 2023.

Flagstaff Housing Corporation ? Clark Homes CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2022 U.S. Department of Housing and Urban Development Flagstaff Housing Corporation - Clark Homes respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 through June 30, 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?FINANCIAL STATEMENT AUDIT SIGNIFICANT DEFICIENCY 2022-001 Residual Receipts and Surplus Cash Deposit Recommendation: Recommend that Project Management compute surplus cash on an annual basis and make full deposit within 90 days as required by regulatory agreement. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: An additional deposit will be made to the Residual Receipts account to correct the shortfall by March 1, 2023. Additional control measures have been added to ensure timely and accurate future deposits. Name(s) of the contact person(s) responsible for corrective action: Kurt Aldinger Planned completion date for corrective action plan: On going If the Department of Housing and Urban Development (HUD) has questions regarding this plan, please call Kurt Aldinger at 928-213-2736.

Finding 2022-005 - Internal Control over Compliance Federal Awards Position(s) of Agency Personnel taking correction action: Chief Financial Officer Corrective Action: Management has implemented procedures to ensure all internal controls over compliance will be performed in such as way as to ensure documentation of compliance. Date Corrective Action Complete: September 30, 2023

2022-002 ? Noncompliance and material weakness for federal awards. The District agrees with this finding and has taken corrective action to ensure that established procedures are followed timely and appropriately. 1) New Braunfels ISD will be contracting with an outside entity to provide an evaluation of business office practices and procedures in order to identify areas in which improvement is needed. 2) New Braunfels ISD has documented due dates for Federal drawdowns so that there is a level of responsibility for all involved in ensuring that these are completed in a timely manner. The due date is the last Friday of each month. 3) The drawdowns will be completed by the Director of Financial Services and backed up by the Assistant Director of Financial Services. They will then be reviewed by the Chief Financial Officer.

Finding No. 2022-002 Authority?s Response and Corrective Action Plan The Authority is participating in a Corrective Action process with the Hartford Field Office regarding the HUD Compliance Review. The Authority is currently reviewing its Procurement Policy to make all necessary updates and train staff on those updates. Person Responsible for Corrective Action Contact; Robert Cappelletti, Executive Director, rcappelletti@meriden-ha.com

The District Business Services office will perform periodic reviews on expenditures related to the Special Education services, to ensure compliance with the Special Education - MOE requirement and that State and Local Funds are properly allocated and utilized for Special Education services. The District will review and utilize annual staffing allocations to assist with compliance of the Special Education - MOE requirement.

Views of Responsible Officials and Planned Corrective Actions: Anita Moreau has implemented policies to ensure all costs are properly authorized and approved by TDA. Anita Moreau has repaid the $20,228 on December 28, 2022. On February 3, 2023, TDA reviewed the Corrective Action Plan provided by Anita Moreau and has concluded its review.

Views of Responsible Officials and Planned Corrective Actions: Anita Moreau has implemented policies to ensure all meal and attendance reports are accrate. Anita Moreau is also encouraging centers to utilize the computer claiming software. These policies have been provided to all centers. On February 3, 2023, TDA reviewed the Corrective Action Plan provided by Anita Moreau and has concluded its review.

Views of Responsible Officials and Planned Corrective Actions: Anita Moreau has implemented policies to ensure all information is captured on the paper enrollment forms. These policies have been provided to all centers. On February 3, 2023, TDA reviewed the Corrective Actiuon Plan provided by Anita Moreau and has concluded its review.