Corrective Action Plans

Name of auditee: National Church Residences of Wayne County, Inc. HUD auditee identification number: 073-EE053-NP-WAH Name of audit firm: Dauby O'Connor & Zaleski, LLC Period covered by the audit: Year ended August 31, 2022 CAP prepared by Name: Jill Kolb Position: Vice President of Housing Accounting Telephone number: 614-451-2151 Current Findings on the Schedule of Findings, Questioned Costs, and Recommendations Statement of condition #2022-001 (Assistance Listing 14.157): During the year ended August 31, 2022, a withdrawal of $335 from the reserve for replacements account without prior approval from HUD. Recommendation: Management should transfer $335 from the operating account to the reserve for replacements account. Action(s) Taken or Planned on the Finding: Management intends to transfer $335 into the reserve for replacements account.

The Department of Human Services (DHS) agrees with the findings. DHS will reach out to the four (4) STAY DC payees to formally request the return of improper payments to the District of Columbia. This will be tracked to ensure the return is recorded against ERA within the District?s financial system. To address any documentation gaps, DHS introduced new Standard Operating Procedures (SOPs) for Family Rehousing and Stabilization Program (FRSP) in FY23. The new SOP implements stricter internal control procedures, regular audits, and streamlining the eligibility determination process. The District will reclass all identified errored payments off of the ERA fund to Local funding by the closeout of FY23, Sept. 30, 2023. DHS also completed a reconciliation of data reported to U.S. Treasury for ERA1 closeout reporting and ERA2 2023 Q2 reporting to ensure that no errored payments were included. See Corrective Action Plan for chart/table

2022-001 Indirect cost rate incorrectly applied to HEERF lost revenue Cluster: Not appliable Grantor: Department of Education Award Name: COVID-19 - Higher Education Emergency Relief Fund (?HEERF?) ? Institutional Portion Award Year: FY2021 Assistance Listing Number: 84.425F Management acknowledges that indirect costs applied to the HEERF Institutional Portion were initially calculated from a base that included lost revenue. Following identification of the error, indirect costs calculated from lost revenue were removed and allowable costs were substituted in and included in amended Q1 2022 and Q2 2022 quarterly reports. Though all HEERF Institutional Portion funds have been expended, management will ensure that indirect costs are calculated from a base that includes allowable costs only. Moving forward, the Director of Post-Award Research Administration and University Controller will review the indirect cost calculation for all grants where lost revenue is an allowable cost. ___________________________ Jonathan Pearsall University Controller (617) 627-3816

Department of Health and Human Services 2022-002 Immunization Research, Demonstration, Public Information and Education, Training and Clinical Skills Improvement Projects - Assistance Listing No. 93.185 Recommendation: We recommend the Foundation attend training, review federal requirements, and fully understand the requirements over indirect costs Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned/taken in response to finding: CFGF will engage with external firm to assist with fully understanding requirements related to indirect costs and federal requirements. CFGF will also work with external firm to assist in the identification and selection of additional training opportunities for staff who work on federal programs. Name(s) of the contact person(s) responsible for corrective action: Brett Hunkins Planned completion date for corrective action plan: December 31, 2023

CORRECTIVE ACTION PLAN FOR THE YEAR ENDED MARCH 31, 2022 Name of Auditee: Citadel Gardens, Inc. HUD Project Number: 084-EE029 Name of Audit Firm: Welch & Associates, LLC Period Covered by Audit: Year Ended March 31, 2022 Corrective Action Plan Prepared by: Name: Fred Gibbs Position: President, Management Agent Telephone Number: (913) 709-1811 Findings-Financial Statement Audit None Findings-Federal Award Programs Audit Federal Agency: Department of Housing and Urban Development Federal Program: Supportive Housing for the Elderly - Section 202 CFDA Number: 14.157 Finding 2022-002 Comments on Findings and Each Recommendation Citadel Gardens, Inc. agrees with the auditors? finding and recommendation. Action(s) Taken or Planned on the Finding Citadel Gardens, Inc. processed the gross rent change to implement the HUD approved rent to be reflected on the September 2022 HAP voucher.

Department: Health and Human Services Title: Internal control over P-EBT Food Benefits needs improvement Questioned Costs: Known: $61,507,558 Likely: None Status: Management?s opinion is that corrective action is not required Corrective Action: The Department disagrees with this finding and does not believe that corrective action is warranted. During the course of the audit, the Department provided the Office of the State Auditor (OSA) with the complete population of recipients as well as the supporting information necessary for OSA to conduct testing to verify compliance with federal program requirements. The only remaining action that is required is for OSA to perform their testing. Completion Date: N/A Agency Contact: Anthony Pelotte, Director, Office for Family Independence, DHHS, 207-624-4104

Grant expenditures that specify a period of coverage and/or performance will be amortized based on the service contract terms. Amortization costs that go beyond a grant?s expiration date will not be recorded against the expired grant.

Condition Found: During audit fieldwork, the auditors spoke to City Staff about the Illinois Environmental Protection Agency (IEPA) Loan reimbursements the City had received during FY2022. The question was whether or not the expenditures we asked to be reimbursed for were eligible because the expense was incurred prior to the loan being approved. The expenditures in question had already been reimbursed to the City from the IEPA and were considered eligible expenditures. When the request from the auditors came for the account numbers that the expenditures had been paid out of, City Staff realized that the majority of these older invoices had been paid with proceeds from the 2015 GO Note issuance, and as such were not eligible to be reimbursed by the IEPA. City Staff relayed this discovery to the auditors and recorded an adjustment to reduce the receivable from the IEPA ($260,749.30) that were not eligible. The City has worked with the consultant managing the project at Baxter and Woodman, and the IEPA, to remedy the issue with a reduction to the City's next distribution. The IEPA loan has not been closed out as of this date, allowing for the reduction without significant impact. Corrective Action Plan: Going forward, the Public Works Department will forward the IEPA Loan draw requests to the Finance Department to be reviewed before being submitted to the IEPA for reimbursement. The Finance Department was not included in the draw request prior to this finding. By having the Finance Department review the draw requests, we can ensure that all items submitted for reimbursement are eligible. Staff at Baxter and Woodman, who package invoices for submittal to the IEPA on behalf of the City, will also be reviewing invoices more closely before submittal as an independent verification. Implementation Date: This change is effective immediately and the Finance Department has already started reviewing the next invoices being submitted to the IEPA for reimbursement.

The DHS and DHCF DCAS team agree with the findings noted in this report. DHS self-reported these findings as part of the Agencies ongoing effort to maintain integrity with all eligibility determinations. The root cause for each of the eleven (11) issues with the ADP system for SNAP varied. For bullet point #1 of the findings noted: ? Action/Phase: Request information from DCAS to determine the magnitude of the deficiency. Expected Outcome: Requested data/information is provided on the identified deficiency. ? Action/Phase: Review and Prioritization - Review data to define scope/magnitude/root cause(s) of deficiency. Expected Outcome: Magnitude of deficiency is determined, and management prioritizes deficiency. ? Action/Phase: Design and Development - Identify and develop corrective actions to address root cause of deficiency. Expected Outcome: Root cause of deficiency is verified, cross-functional team selects actions to resolve root cause(s) actions tested, as applicable. ? Action/Phase: Implement - Implement approved corrective actions and measure/metrics to monitor effectiveness of corrective action. Expected Outcome: Management approves actions, actions implemented along metrics/measures. ? Action/Phase: Monitor and Evaluation - Ensure the changes are successful. Expected Outcome: Once corrective actions are identified, a monitoring and evaluation plan will be developed and implemented to determine if the implemented actions substantially reduce/eliminate the deficiency from occurring. In March 2023, a request to run this report was made. The run took place in April 2023 and ultimately found that the report could not be derived. Ultimately the request/ticket below will be closed. For bullet point #2 of the findings noted: ? Action/Phase: Request information from DCAS to determine the magnitude of the deficiency. Expected Outcome: Requested data/information is provided on the identified deficiency. ? Action/Phase: Review and Prioritization - Review data to define scope/magnitude/root cause(s) of deficiency. Expected Outcome: Magnitude of deficiency is determined, and management prioritizes deficiency. ? Action/Phase: Design and Development - Identify and develop corrective actions to address root cause of deficiency. Expected Outcome: Root cause of deficiency is verified, cross-functional team selects actions to resolve root cause(s) actions tested, as applicable. ? Action/Phase: Implement - Implement approved corrective actions and measure/metrics to monitor effectiveness of corrective action. Expected Outcome: Management approves actions, actions implemented along metrics/measures. ? Action/Phase: Monitor and Evaluation - Ensure the changes are successful. Expected Outcome: Once corrective actions are identified, a monitoring and evaluation plan will be developed and implemented to determine if the implemented actions substantially reduce/eliminate the deficiency from occurring. DCAS system will be fixed no later than FY2024 Q3. For bullet point #3 of the findings noted: ? Action/Phase: Request information from DCAS to determine the magnitude of the deficiency. Expected Outcome: Requested data/information is provided on the identified deficiency. ? Action/Phase: Review and Prioritization - Review data to define scope/magnitude/root cause(s) of deficiency. Expected Outcome: Magnitude of deficiency is determined, and management prioritizes deficiency. ? Action/Phase: Design and Development - Identify and develop corrective actions to address root cause of deficiency. Expected Outcome: Root cause of deficiency is verified, cross-functional team selects actions to resolve root cause(s) actions tested, as applicable. ? Action/Phase: Implement - Implement approved corrective actions and measure/metrics to monitor effectiveness of corrective action. Expected Outcome: Management approves actions, actions implemented along metrics/measures. ? Action/Phase: Monitor and Evaluation - Ensure the changes are successful. Expected Outcome: Implementation of DCAS Release Part 2 was completed on March 26, 2023. The District requested FNS close this finding. Implementation of DCAS Release Part 2 was completed on March 2023. The District is requesting that this finding be closed. For bullet point #4 of the findings noted: ? Action/Phase: Request information from DCAS to determine the magnitude of the deficiency. Expected Outcome: Requested data/information is provided on the identified deficiency. ? Action/Phase: Review and Prioritization - Review data to define scope/magnitude/root cause(s) of deficiency. Expected Outcome: Magnitude of deficiency is determined, and management prioritizes deficiency. ? Action/Phase: Design and Development - Identify and develop corrective actions to address root cause of deficiency. Expected Outcome: Root cause of deficiency is verified, cross-functional team selects actions to resolve root cause(s) actions tested, as applicable. ? Action/Phase: Implement - Implement approved corrective actions and measure/metrics to monitor effectiveness of corrective action. Expected Outcome: Management approves actions, actions implemented along metrics/measures. ? Action/Phase: Monitor and Evaluation: Ensure the changes are successful. Expected Outcome: Once corrective actions are identified, a monitoring and evaluation plan will be developed and implemented to determine if the implemented actions substantially reduce/eliminate the deficiency from occurring. The data needed from DCAS to determine the scope/magnitude has not yet been provided. However, DCAS considers this as a high priority ticket for Releases 4 and 5. See Corrective Action Plan for chart/table

Campton Methodist Housing II, Inc. respectfully submits the following Corrective Action Plan for the year ended August 31, 2022. Name and address of the independent public accounting firm who conducted the related audit: Comer, Nowling And Associates, P.C. 10475 Crosspoint Boulevard, Suite 200 Indianapolis, Indiana 46256 Finding 2022-001 Corrective Action Planned ? Management deposited $250 into the tenant security deposit account on October 21, 2022. Contact Person(s) Responsible ? Leta Swift, Accounting Director Anticipated Completion Date ? October 21, 2022 Auditee Disagreements ? N/A This corrective action plan was prepared by Homeland, Inc., the management company, on behalf of Campton Methodist Housing II, Inc.. Homeland, Inc. P.O. Box 619 Leithcfield, KY 42755 270.259.5461 Signature _______________________________________ Date: October 28, 2022

Special Tests and Provisions ? Wage Rate Requirements There is no disagreement with the finding. Management immediately began to review policies and procedures. District Contacts: Mark Boehlke, Assistant Superintendent, Business and Operational Services Wendy Baackes, Coordinator of Financial Services Finding 2022-002 expected to be corrected during the 2022-23 fiscal year.

Housing service leadership staff will ensure that each unit lease served through NWYS will have on file documentation of reasonable rental rates and residential use at the time of lease signing or renewal, to ensure compliance with all grant requirements.

The District will make sure every project abides by the prevailing wage law.

The Executive Director will implement measures to ensure that the most recent ICRA is utilized on drawdown requests.

2022-001 Eligibility ? Aggregate Loan Limits for Subsidized and Unsubsidized Loans Contact: Jeffrey C. Straits Title: Chief Financial Officer Phone Number: (202)885-8684 Anticipated Completion Date- Done Corrective Action Wesley Theological Seminary will ensure that the loans disbursed by the Institution are within the loan limits prescribed in the OMB Compliance Supplement. Wesley acknowledges that before outsourcing our financial aid processing, there was a breakdown in the Seminary following policies, procedures, and controls within financial aid, which allowed these errors. The Seminary will review all policies and procedures related to this control. We will also complete a review of all active federal loans for the fiscal year 2022 to identify if there are further processing errors allowing loans above the aggregate loan limits. Wesley management will also implement quarterly testing of randomly selected student loan transactions. The testing will include the verification of eligibility for aggregate loan totals, good standing, and satisfactory academic progress. The results of this testing will be reviewed by the CFO and maintained by Wesley?s management. Status as of November 2022 Wesley Theological Seminary outsourced our financial aid processing in January 2022. Wesley will ensure the work prepared by outsourced personnel is reviewed properly and such review is documented properly. All of the errors found were processed by our internal Financial Aid Director before the outsourcing of financial aid processing. We completed the review of all students who received Federal financial aid in the fiscal year 2022. There were seven students with awards over the aggregate maximum (including those previously identified by BDO). The total amount awarded over the per-person aggregate limit was $79,159. Our outsourced financial aid processor will ensure the review of total student debt prior to processing a loan, as required in our policies and procedures. Wesley management has reviewed our policies and procedures related to this issue. To verify ongoing compliance of our outsourced financial aid processor with our financial aid policies, procedures, and controls, we are adding a requirement of quarterly random testing of students? records for the verification of eligibility for aggregate loan totals, good standing, and satisfactory academic progress. Wesley management has completed the fiscal year 2023 first quarter review of random students? transactions, and we did not find any errors. The testing results were reviewed by the CFO and maintained by Wesley?s management.

2022-003 Errors in Support Summarizing/Reconciling Allowable Costs in Reporting and No Formal Documentation of Review of Reports Recommendation: We recommend the County review its procedures relative to allocating costs and reviewing support provided for reporting to Federal programs Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The County will keep reporting records for detailed documentation of expenses, along with quarterly filing reports to ensure balancing of all Federal Reporting to New World Name(s) of the contact person(s) responsible for corrective action: Larry Baughn, Board Chairman Planned completion date for corrective action plan: Quarterly Reporting ending March 31, 2023.

Recommendation: We recommend that the District implement procedures to review that expenditures claimed under the program are allowable and are not already claimed. Action taken: Cathy Meher, treasurer, reviewed this with the external auditors and those questioned costs had not been claimed for reimbursement and will be reviewed prior to submission to Grants Finance for reimbursement. Dr. Christopher Wojeski, Assistant Superintendent, will also review the expenditures to ensure they are allowable costs. With the addition of a new staff member in the Business Office, this will be addressed and corrected immediately. Anticipated completion date: 11/1/22

Identifying Number: 2022-003 Finding: The University improperly discharged a student's debt who did not meet the guidelines of their debt discharge policy. Corrective Actions Taken or Planned: The procedures surrounding the spending of CARES Act funding, including the discharge of student debt, were established in 2021-2022 and were outside of the normal scope of business. These funds have been exhausted. If additional funding becomes available and student debt is again eligible for discharge, Mount Mercy will add a second layer of detailed review to ensure each student is properly discharged per the guidelines established. Persons Responsible and Completion Date: Brittney Burmahl, Controller, and Anne Gillespie, Vice President for Business & Finance, October 31, 2022

Identifying Number: 2022-001 Finding: A student was improperly awarded and disbursed a TEACH grant. Corrective Actions Taken or Planned: In April 2021, Financial Aid Staff collected TEACH Grant counseling for two academic years (20-21 and 21-22) at the same time and awarded the grant for both academic years based on the GPA as of that date. The student was eligible for 20-21, but at the end of the 20-21 academic year, their GPA had dropped below the 3.25 requirement, making them ineligible for the grant in 21-22. The Financial Aid Staff did not double check the GPA after 20-21. The TEACH Grant was refunded to the Department on 6/30/22. An additional step was added to our manual that requires all TEACH Grants set up prior to the first origination will be double-checked to verify eligibility. Persons Responsible and Completion Date: Mark Freed, Director of Financial Aid, June 30, 2022

Identifying Number: 2022-002 Finding: Students were never awarded and disbursed FDL funds and under awarded an disbursed FSEOG funds. Corrective Actions Taken or Planned: Students identified were awarded aid to cover the error on 6/30/22. All student enrollment is checked at the start of the term; however, our modular students are allowed to make schedule changes throughout the semester. A report has been generated to review enrollment changes weekly to properly update any necessary aid changes. Persons Responsible and Completion Date: Mark Freed, Director of Financial Aid, June 30, 2022

2022-001 Federal Work Study - Student Financial Aid Cluster Assistance Listing Number 84.007, 84.033, 84.063, 84.268, Grant Period - Year Ended June 30, 2022 Condition Found During our Federal Work Study testing, we selected eleven students and noted that one student was paid for hours they did not work. The College did not review federal work-study hours worked against class hours scheduled and timesheets to ensure the student was not working during a scheduled class and that they were paid for the correct number of hours. We consider this condition to be an instance of non-compliance to the Activities Allowed or Unallowed compliance requirement. Corrective Action Plan In addition to direct counseling with the supervisor and student workers partied to this practice, the Financial Aid and Human Resources offices implemented several steps to stress the supervisor?s responsibility for timesheet validation. The changes went into effect on August 5, 2022. The steps included: 1. Reviewed the Student Worker Employee Handbook and Student Worker Supervisor Handbooks to confirm that language exists addressing that students should not work during scheduled class time, and supervisors are responsible for reviewing timesheets before approval submission. 2. All Supervisors are now required to review and sign off on the Supervisor Student Worker Handbook annually. Human Resources will audit for compliance quarterly. 3. At the start of each new academic year, Financial Aid and Human Resources will host a ?Hiring a Student Worker Information? session for all supervisors. This year the session took place on September 1, 2022. This session stress timesheet reviews, among many other responsibilities. Responsible Person for Corrective Action Plan Mary Greenwood, Director of Student Financial Aid Services, will be the person responsible for this Corrective Action Plan. Implementation Date of Corrective Action Plan As of August 5, 2022, all phases of the Corrective Action Plan were implemented.

Contact Person Responsible for Corrective Action: Tyler C. Osenbaugh Contact Phone Number: 260-336-0217 Views of Responsible Official: Agree with the finding Description of Corrective Action Plan: The School Food Authority and Food Service Director (Chartwells? Director of Dining Services) review and validate the supporting documentation for all food service-related purchases. The documentation, include payroll information and non-payroll expenditures, including vendor deliveries. Copies of the supporting data have been retained by the Business Manager to ensure records are available for audits. The review occurs prior to the SFA submitting for reimbursement into CNPWeb. These steps have been in place correcting the previous finding (2020-002). Future reviews will include supporting vendor (Gordon Food, Piazza, Prairie Farms) price lists in effect during the support period. The prices paid for commodities from these vendors will be compared to Chartwells Operations Ledger to ensure charges are consistent with the costs. Anticipated Completion Date: May 2023

Elder Care Two Inc. June 30, 2022 Corrective Action: Elder Care 2 Finding 2022-001 over payment of Payroll Reimbursement: Management will make an adjustment to the billing of payroll for September 1, 2022 to correct for the over billing . Responsible party: Michelle Cabana

FINDING 2022-004 Name of Responsible Individual For Finding(s): Bryan Soady, Former Alliance Executive Director Name of Responsible Individual For Correction(s): Awisi Bustos, Current Alliance Executive Director Corrective Action: The Alliance will enhance its procedures and internal controls over record retention to ensure complete and accurate financial reporting. Anticipated Completion Date: September 30, 2023

FINDING 2022-003 Name of Responsible Individual For Finding(s): Bryan Soady, Former Alliance Executive Director Name of Responsible Individual For Correction(s): Awisi Bustos, Current Alliance Executive Director Corrective Action: The Alliance will enhance its procedures and internal controls over subrecipient monitoring to ensure local club invoices are properly reviewed. Anticipated Completion Date: September 30, 2023