Corrective Action Plans

Condition: Expenditure reports were not filed accurately by claiming unallowable expenses. Recommendation: We recommend that steps are taken, including oversight by a second employee, to ensure that expenditure reports are reviewed are allowable expenses and that all expenses are after the grant start date before submitting the reports. Management Response: Management will take the necessary steps to file all quarterly expenditure reports accurately in the future. Anticipated Date of Completion: June 30, 2023.

Finding: 2022-008 Our Katahdin has engaged a contractor who has attended training to gain knowledge and expertise in grant administration. This training was initiated in August of 2022 and is ongoing as available. The organization will review other disbursements and ensure they are appropriate, reimbursable costs. Responsible official: Nancy DeWitt, Treasurer (207) 618-9187 Expected completion date: October 31, 2023

See Corrective Action Plan for chart/table

Finding 2022-001 - U.S. Department of Education (USDE). Title IV Student Financial Aid Programs (material weakness}: We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs. a. Three (3) out of 60 students tested had missing official transcripts with total questioned costs of $36,516. b. Twelve (12) out of 26 students tested did not have refunds given to students within the required 14 days. c. Two (2) out of six (6) students tested for R2T4 did not have Title IV funds returned to the Federal government within the required 45 days. The University should implement corrective actions to ensure that the above findings are resolved and will nor recur in future periods. Corrective Action - The College concurs with the finding. The College continues to be challenged with finding qualified staff in the Financial Aid Office and Business Office. The College will be working closely with staffing companies to identify qualified personnel. The College is working diligently to ensure all positions are filled to ensure compliance with all federal and state regulations. We understand the seriousness of these findings and implementing appropriate strategies to minimize and/or eliminatefurther auditfindings. TheCollege plans to start implementing these strategies beginning July 1, 2023.

Finding 2022-001 - U.S. Department of Education (USDE}, Title IV Student Financial Aid Programs (Significant Deficiency): We observed the following conditions in connection with our testing of the various U. S. Department of Education, Title IV, Student Financial Assistance Programs: ? Title IV awards for six (6) of twelve (12) students sampled for Return of Title IV (R2T4) did not have funding returned within the required 45-day time frame with total questioned costs of $18,768. ? The College had differences in the following programs which were not reconciled to the general ledger: Program Description Federal Work-Study Federal Direct Student Loans ? FISAP Work-Study totals did not match general ledger totals. Recommendation - We recommend the College implement corrective actions to ensure the above findings are resolved and do not recur in future periods. Moreover, internal controls over compliance with Federal program regulations should be revisited to ensure adequate supervisory controls, quality assurance reviews of compliance steps, technical training of staff, and adequate procedures are being followed for compliance purposes. Corrective Action - The Office of Financial Aid understands the seriousness of these findings and are implementing appropriate strategies to minimize and/or eliminate further audit findings, including: ? Conduct monthly reconciliations between the Business and Financial Aid Offices reviewed and approved by the Vice President of Finance and Administration. ? Provide specialized Title IV training for the Financial Aid staff through resources and services provided by our auditors, The Wesley Peachtree Group, CPAs to improve and ensure processes align with federal reporting guidelines.

(Significant Deficiency) We observed the following conditions in connection with our testing of the various U. S. Department of Education, Title IV, Student Financial Assistance Programs: 1. Enrollment status reporting to NSLDS for four (4) students tested was not provided as required by Federal regulations. 2. The Center did not provide the Common Origination and Disbursement (COD) funding report for the entire 2021-2022 award year for Federal Direct Loans. As of the report date, the Center had requested it from the U.S. Department of Education. Recommendation ? The Center should implement corrective actions to ensure that the above findings are resolved and do not recur in future periods. Moreover, internal controls over compliance with federal program regulations should be revisited to ensure adequate supervisory controls, quality assurance reviews of compliance steps, technical training of staff, and adequate procedures are being followed for compliance purposes. Corrective Action ? The enrollment information was provided to the FA auditor and several inquiries were made for verification and no timely response was received from the FA auditor. Three versions of the COD reports were provided along with several inquiries for confirmation that the report is what was needed. No timely response was made to our request. Management further explained that it takes 24 hrs. to receive the revised report if what was submitted was not what was needed, again no timely response from the FA auditor.

Finding 2022-004: Significant Deficiency - Return of Title IV Funds Calculations Condition: For 3 students selected for testing, the amount of the title IV refund was calculated incorrectly. Corrective Action: The errors were made because the incorrect terms dates were entered into Colleague by the Registrar's Office. Moving forward, the Financial Aid office will work with the Registrar's Office to ensure the term dates are entered correctly in Colleague. After the Registrar's Office enters the term dates in Colleague, the Associate Vice President of Student Financial Systems will review the entries for accuracy. Person Responsible for Corrective Action: Matt Thomsen - VP of Enrollment; Todd Knealing VP of Academic Affairs Anticipated Completion Date: 8/1/2023

Finding 2022-003 - U. S. Department of Education (USDE). Title 111a1n d TRIO Programs: The College had excess cash in the Title Ill Program, and the TRIO Programs of Upward Bound, and Student Support Services at June 30, 2022 as follows: Programs Title Ill Upward Bound Student Support Services ExcessC ash $1,482,097 $ 51,010 $ 253,195 Corrective Action - Management concurs with the observation. The College will Implement a plan to repay the excess cash in the upcoming future years to eliminate the excess cash balances.

Finding 2022-002 - U.S. Department of Education (USDEJ. Title IV Student Financial Aid Programs (deficiency}: We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs: 1. One (1) out of 10 students tested did not have timely or accurate enrollment reporting to the National Student Loan Data System (NSLDS). 2. One (1) out of 60 students tested was overpaid Pell funds. The over awarded funds were subsequently returned. 3. One (1) out of 60 students tested was not eligible for but was awarded Federal Supplemental Educational Opportunity Grant (FSEOG). The University subsequently returned the ineligible grant amount. 4. One (1) out of 60 students tested showed a discrepancy during verification testing where we observed tax documents submitted with an incorrect social security number. The questioned cost is $5,195. 5. Two (2) out of Five (S) students tested did not show the returned amount on the student's statement of account during R2T4 testing. Both statements of account were subsequently updated with the returned amounts. Corrective Actions - 1. NSLDS reporting is actively reconciled monthly with our financial aid servicer and, as of August 18, 2022, the University confirmed 97.18% reported. The University will continue to actively monitor this reporting to ensure accuracy and timeliness. 2. The University will monitor and review the process of enrollment more thoroughly with the third-party financial aid processor to ensure all non-enrolled students are not included in payment batches. The University has moved to a new third-party financial aid processor in a further effort to ensure compliance with Title IV regulations. 3. The University will monitor and review the process of enrollment more thoroughly with the third-party financial aid processor to ensure all non-enrolled students are not included in payment batches. The University has moved to a new third-party financial aid processor in a further effort to ensure compliance with Title IV regulations. 4. The University will monitor and review the process of verification more thoroughly with the third-party financial aid processor to ensure all applicable steps are taken and that all information is accurate. The University has moved to a new third-party financial aid processor in a further effort to ensure compliance with Title IV regulations. 5. The University has implemented a new student information system, as well as processes to ensure that Title IV transactions are applied timely to student ledgers. The University also notes that, in the case of this finding, the Title IV funds were returned timely and accurately.

A. Comments on Findings and Recommendations: We agree with the finding and recommendation. B. Actions Taken or Planned: By November, the Vice President of Financial Aid will update the Withdrawal Checklist to include a final enrollment field to notate the number of hours enrolled. The Withdrawal Checklist will also include a checkbox to notate that all financial aid has been updated to the proper enrollment status prior to completing the R2T4 calculation.

Finding 2022-001 ? U.S. Department of Education (USDE), Title IV Student Financial Aid Programs (Significant Deficiency): We observed the following conditions in connection with our testing of the various U.S. Department of Education, Title IV, Student Financial Assistance Programs. ? Two (2) out of five (5) students tested for R2T4 calculations and refunds did not have funds returned back to the U.S. Department of Education within the required 45 days. Auditor?s Recommendation ? The University should implement corrective actions to ensure that the above finding is resolved and will not recur in future periods. Corrective Action ? With regard to the return of funds back to the U.S. Department of Education, employee turnover at the University caused this delay. The University returned all funds as required and is currently filling positions with competent employees to handle these processes.

Finding: 2022-003 Department of Commerce Response/Corrective Action Plan: The Department of Commerce agrees with this finding. The agency has attempted several times to obtain allowable expenditures under the fund with no cooperation from the beneficiary. The beneficiary was turned over to the North Dakota Attorney General Office on August 13, 2020, to recoup the grant award and refund the U.S. Department of the Treasury. Contact Person: Shawn Kessel, COO/Deputy Commissioner Anticipated Completion Date: December 2024 is the anticipated completion date for this finding as the beneficiary has been turned over to the North Dakota Attorney General's Office to recoup the grant award.

Finding: 2022-002 Department of Commerce Response/Corrective Action Plan: The Department of Commerce agrees with this finding. The Department of Commerce utilized the funds made available to it by the 67th Legislative Assembly to accomplish the intent of said legislative body. The Agency is working with the current legislative body and the North Dakota Office of Management and Budget to resolve this finding. Contact Person: Shawn Kessel, COO/Deputy Commissioner Anticipated Completion Date: On or before July 1, 2023

2022-2 Condition: Deficiencies Noted in the Maintenance Debit and Credit Cards Steps to resolve: We will review the internal control procedures over the maintenance of debit and credit cards. Management will implement procedures to clear this finding in FY 2023. Timeframe: By FYE September 30, 2023 Individual responsible for correction: LaShanda Lovette, Executive Director

FA 2022-001 Strengthen Controls over Expenditures Compliance Requirement: Activities Allowed or Unallowed Allowable Costs/Cost Principle Internal Control Impact: Significant Deficiency Compliance Impact: Nonmaterial Noncompliance Federal Awarding Agency: U.S. Department of Education Pass-Through Entity: Georgia Department of Education Assistance Listing Number and Title: COVID-19 - 84.425D - Elementary and Secondary School Emergency Relief Fund Federal Award Number: S425D200012 (Year: 2020), S425D210012 (Year: 2021) Questioner Costs: $187,246 Prior Year Finding: No Description: A review of expenditures charged to the Elementary and Secondary School Emergency Relief Fund program revealed that the School District's internal control procedures were not operating appropriately to ensure that expenditures were allowable. Corrective Action Plans: The questioned cost noted above was considered for financial reporting purposes, and a prior period adjustment to classify the expenditure to the appropriate grant was made in March 2023. In addition, the questioned cost amount was not included in the Schedule of Expenditures of Federal Awards for the year-ended June 30, 2022. In the future, the School District will review all federal expenditures for appropriateness appropriateness and allowability including a budget to actual comparison and follow-up on any significant differences. In addition, the program manager of each grant will review the details of all grant activity as part of the year-end process to ensure completeness. Estimated Completion Date: Effective with June 30, 2023 Year-End Process Contact Person: Melanie James, Assistant Superintendent of Business and Finance Telephone: 912-851-4000 Email: mjames@bryan.k12.ga.us

Corrective Action Plan For the Fiscal Year Ended December 31, 2022 The finding from the December 31, 2022 schedule of findings, questions costs, and recommendations is discussed below. The finding is numbered consistently with the numbers assigned in that schedule. FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2022-01: Allowable Costs ? U.S. Department of Health and Human Services, CCBHC Planning, Development and Implementation Grant ? Assistance Listing Number 93.696 according to 45 CFR ? 75, and the HHS Grants Policy Statement Description of Finding: Costs incurred outside the budget period are not allowed under the grant. Certain costs incurred prior to the budget period were included in costs which were reimbursed during the year ended December 31, 2022. Statement of Concurrence or Nonconcurrence: We concur with the finding and recommendation. Corrective Action: Management will implement an additional review step to evaluate the timing of when such costs are incurred in order to meet the grant requirements. We will also ensure reimbursement of the unallowable costs will be remediated by reducing amounts reimbursed during 2023. Name of Contact Person: Carrie Geske, Controller 612-798-8375 carrie.geske@fraser.org Projected Completion Date: August 2023 If the U.S. Department of Health and Human Services has questions regarding this Plan, please call Carrie Geske at 612-798-8375.

CORRECTIVE ACTION PLAN FOR FINDINGS REPORTED UNDER UNIFORM GUIDANCE Richland School District No. 400 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: Cynthia Robinette, Assistance Finance Director 6972 Keene Rd West Richland, WA 99353 Corrective action the auditee plans to take in response to the finding: This audit finding related to unique rules associated with one-time, pandemic-necessitated funding, so RSD is extremely unlikely to have to navigate these compliance expectations ever again. However, RSD will aspire to slow down the procurement and deployment of grant-funded resources as long as possible in the future in order to learn more of what the final audit expectations may be. Anticipated date to complete the corrective action: Undeterminable based on rarity of event

Corrective Action Plan Federal Award Findings and Questioned Costs For the Years Ended December 31, 2020 and 2021 Finding 2022-002 ? A. Activities Allowed or Unallowed; B. Allowable Costs/Cost Principles; L. Reporting Federal program information: Federal Program: 93.948, COVID-19 Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Federal Agency: U.S. Department of Health and Human Services (HHS), Health Resources and Services Administration (HRSA) Locations: Various Award Numbers: Various Award Period: January 1, 2020 through June 30, 2022 Summary of finding: UC Health did not have effective internal controls in place to ensure expenses and lost revenues reported in the Portal were not duplicated. This resulted in the overstatements of expenses and lost revenues reported in the Portal. Planned corrective action: Management will establish processes for reviews of the reporting guidelines to better interpret and comply with the guidelines for future reporting. Anticipated completion date: Prior to next filing due September 30, 2023 Responsible contact person: Michael Wiedeman, Vice President and Controller

New Directions DHS is exploring different possibilities to satisfy the audit finding to include the contracting of a certified public accounting firm to assist in conducting the financial portion of our subrecipient monitoring. Alternatives to Abortion Office of Policy Development (OPD) initiated numerous conversations with the Alternatives to Abortion grantee regarding receiving the requested documentation for monitoring (communication occurred regularly from April 2021 through January 2023). The grantee disagrees that the disclosure of this information is a requirement of the grant agreement and as such has not provided the documentation needed to complete the monitoring. On October 27, 2022, DHS sent a letter to the grantee outlining specific action steps to establish compliance with their grant agreement. The grantee responded on November 28, 2022, disputing the claims of DHS and asserting that they are not out of compliance with their grant agreement. OPD will be scheduling time to visit the grantee to review documents required by the terms of their grant agreement in order to complete the monitoring. Monitoring will occur by June 30, 2023. Anticipated Completion Date: New Directions- 03/01/2024; Alternatives to Abortion- 06/30/2023 Contact Person and Title: New Directions- Joel O?Donnell, Director, Bureau of Program Support, OIM; Alternatives to Abortion- Ana Arcs, Acting Policy Director, OPD

DHS: The Office of Children, Youth, and Families (OCYF) is sending out a Restrictions and Requirements document with each tentative and final allocation letter. This document lists all OCYF?s grants, the federal agency granting the fund and where to find the rules and regulations guiding the usage of the funds. For the State fiscal year 2021-2022, Tentative Allocation Letters were sent out on April 1, 2021, with Federal Award Identification Numbers (FAIN) and funding amounts. Final Allocation Letters were sent out August 12, 2021, with the Amount, FAIN and Name. OCYF has a risk assessment process in place for Title IV-E and TANF awards. During the Quality Assurance reviews, which occur twice a year at a minimum, OCYF reviews a sample of Title IV-E eligible foster care cases, Title IV-E ineligible foster care cases, Title IV-E eligible adoption assistance cases, and TANF eligible cases. Depending on the number of eligibility and claiming errors identified during the review, OCYF schedules more frequent visits as the risk of repeated and continued errors in these County Children and Youth Agencies (CCYAs) is higher. Inaccurate eligibility determinations lead to inaccurate federal claiming, so basing the review schedule on a CCYA?s eligibility review outcome allows OCYF to target those CCYAs where inaccurate claiming is a higher risk. However, to further address this finding, the risk assessment now includes documentation. Anticipated Completion Date: Completed Contact Person and Title: TinaMarie Petrovitz, Director of County Support DOH: The Department plans to develop and implement a robust subrecipient monitoring program which includes establishing a new section within the Budget Office pending enacted budget funds and complement to support the creation of the section. Initiative goals/milestones include: - Assessment: Comprehensive assessment of all current federal grants and subawards and their processes. This assessment will document best practices and identify gaps within the agency?s processes. It will also provide an evaluation of current operational and technological resources that can be leveraged to facilitate compliance. Target start date: February 27, 2023. Target completion date: June 30, 2023. - Educate Department: Budget Office is developing a bulletin that will outline the subrecipient monitoring requirements with links to State and Federal Sources. The bulletin will be shared with all program office staff. The Budget Office will develop the following templates and provide to all program offices: - Determination of vendor status: Subrecipient or Contractor - Risk Assessment Form - Internal Control Self-Assessment for Subrecipient Template - Subrecipient Monitoring Template All materials will be updated with any additional information gained during the assessment. Start date: February 3, 2023. Target Completion Date: June 30, 2023 - Implementation of full compliance initiative: Recommendations provided in the assessment will be used to develop and implement comprehensive policies and procedures led by a new section in the Budget Office. Target start date July 1, 2023. Target fully operational date: June 30, 2024. Anticipated Completion Date: 06/30/2024 Contact Person and Title: Andrea Race, CFO

PDE uses its eGrants system to collect all LEA required records under ESSER I and ESSER II. The eGrants system is designed to allow licensed educational agencies and certain community-based programs within the Commonwealth, access to PDE grants. Through this system, the LEA can submit applications for funding, e-sign contracting documents, upload back-up documentation, submit program quarterly reports, and file final expenditure reports. PDE Division of Federal Programs also utilizes Pennsylvania's Information Management System (PIMS) to collect and verify LEA data. PIMS has business rules built in to ensure valid data collection. The eGrants system makes it possible for records pertaining to the ESSER awards to be retained separately from other grant funds, including funds that an SEA or LEA receives under the CARES Act and CRRSA. This follows the requirements under 2 C.F.R. ? 200.334 and 34 C.F.R. ? 76.730, including financial records related to the use of grant funds. Through quarterly financial reporting, LEAs are required to report the amount of cash received, expended, and on hand. If the amount of cash-on-hand reported is determined to be too high, or the quarterly report is not submitted, monthly payments will be suspended until the next quarterly report is due. Current monitoring to verify data and ensure compliance with existing federal guidelines, typically occurs from January through May. LEAs receive a unique username and password to access Fedmonitor and complete an online self-assessment. Beginning in October 2022, all LEAs were placed on a four-year monitoring cycle and were monitored in the 2021?22 fiscal year and will be monitored again in the 2024?25 fiscal year. Data collected in eGrants, PIMS and Fedmonitor is verified during these monitoring visits. Anticipated Completion Date: Completed Contact Person and Title: Susan McCrone, Division Manager, Federal Programs; Brian Campbell, Director, Bureau of Curriculum, Assessment, and Instruction

Similar to other DHS programs, DHS has implemented an after-action review of information submitted, using a contracted vendor. DHS faced challenges implementing a program with 67 counties and no central eligibility determination system. DHS has learned that implementing the supportive services and multi-sector partnerships was challenging in the context of the global pandemic and workforce shortages. This made DHS dependent on local county reports to maintain program oversight and compile statewide data for submission to US Treasury. DHS plans to strengthen this control as we plan for future emergency or pandemic programs related to rental assistance. Anticipated Completion Date: 06/30/2023 Contact Person and Title: Joel O?Donnell, Director, Bureau of Program Support, OIM

AMLR program representatives attended Department of Interior, Office of Surface Mining Reclamation and Enforcement online training covering 2 CFR 200 and contractor or subrecipient determinations. DEP ceased issuing AMLR grants under Management Directive 305.20, Grant Administration. DEP management has determined the recipients with existing agreements are subrecipients and DEP will follow this determination consistently with future agreements and accounting. DEP has developed written policies and procedures for subrecipient monitoring and has notified grantees to implement the policies and procedures immediately to ensure timely subrecipient compliance with federal regulations. Anticipated Completion Date: Completed Contact Person and Title: Patrick Webb, Acting Dir., Bureau of AMLR; Tim Golding, Executive Assistant, Office of Admin. and Management

PDE: Audits retrieved from the Federal Audit Clearinghouse are now reviewed after entry into PDE?s SharePoint website, to ensure PDE remains compliant with federal guidelines to respond to any and all findings pertaining to federal dollars it passes to subrecipients. Likewise, PDE Audit Section continues to improve upon its processes for timely determinations of those single audits with findings by multiple means, including periodic SharePoint enhancements designed to aid in timely review of single audit packages, working closely with PDE program areas to assist in timely responses and quickly addressing SharePoint access issues as they arise. Anticipated Completion Date: 06/30/2023 Contact Person and Title: Clayton P. Carroll, II, Audit Coordinator; Jessica Sites, Director, Bur. of Budget and Fiscal Mgmt DEP: BAFM now provides agencies with single audit reporting packages that have findings each week that have been accepted by the Federal Audit Clearinghouse (FAC). This allows for us to start our management decision process in a timelier manner and meet the six-month deadline for issuing our decision. This information first appeared in our notifications starting April 30, 2021. In addition, the DEP program that had been previously identifying agreements as contracts rather than subrecipient agreements has corrected this issue and all subrecipients have been notified in writing of this correction and provided the information for submitting their single audits (if necessary). The letters were sent to subrecipients on approximately May 31, 2022. DEP Fiscal Management staff will continue to monitor the BAFM SharePoint site and FAC for additional filings to attempt to avoid this issue in the future. DEP is also hiring additional staff for the oversight and monitoring of the subrecipient single audits to ensure compliance with all requirements. These positions are currently in the filing process, and we are hopeful that they will be filled, and staff trained by September 30, 2023. Anticipated Completion Date: 09/30/2023 Contact Person and Title: Jennifer L. Brandt, Senior Fiscal Management Specialist, Federal Grants and Audits DOH: NORTH Inc.?s Single Audit report for the period ending 9/30/2020 was officially submitted and showing on the FAC on 2/9/2023. Bureau of WIC staff reached out to the Director and CFO of NORTH Inc. by phone and email. Emails were sent with instructions on how to submit the report as well as the importance of submitting the report timely per their grant agreement. Each follow-up phone call included discussion on the importance of submitting their single audit as soon as possible. Moving forward the Bureau of WIC will implement the following procedure: 1 .Three months after the end of the audit period (Federal Fiscal Year), Project Officers will send an email that outlines the process for submitting a single audit reporting package to the FAC to their respective WIC local agencies. This email will provide a date that the single audit is due to be submitted to the FAC in order to stay in compliance with their current WIC grant agreement. 2. Six months after the end of the audit period (three months from the due date of the single audit reporting package) an official letter from the Bureau Director will go out to the WIC local agencies that are due to submit a single audit. The letters will include instructions on how to submit the single audit in FAC and the Audit Requirements link referenced in their grant agreement. 3. If the WIC local agency notifies the Bureau of WIC that their auditor will not be able to submit their agency?s single audit by the due date, then the Project Officer will work with the local agency to get a projected date of completion and a timeline on when the local agency?s auditor is able to finalize the audit and submit it to the FAC. The Bureau of WIC will then notify DOH?s Audit Coordinator and OB-BAFM of this information, so they are able to track it. 4. If the WIC local agency does not submit the report by the due date and fails to notify their project officer; a notice to cure letter will be sent to the agency. Concerning NORTH Inc.?s Single Audit report for the period ending September 30, 2021: 1. The Bureau of WIC will contact NORTH Inc. and request a meeting with their auditor. 2. Following the meeting with NORTH Inc.?s auditor, the Bureau Director will send an official letter to NORTH Inc. The letter will include the instructions on how to submit the single audit in the FAC and the Audit Requirements link referenced in their grant agreement. They will also be made aware of the actions that could result from them not submitting this audit by the agreed upon date. 3. If the single audit is not received by the agreed upon date, then the Bureau of WIC will send a notice to cure letter. Anticipated Completion Date: 03/24/2023 Contact Person and Title: Sally Zubairu-Cofield, Director, Bureau of WIC DHS: Regarding the timeliness of finding resolution and procedures related to the SEFA reviews, the Audit Resolution Section (ARS) hired an additional staff member in August 2021 and hired two additional staff members in February 2022, and an additional staff member in January 2023. Finally, the ARS worked with Office of the Budget, Bureau of Accounting and Financial Management to develop a risk-based approach for single audit reviews, which will greatly streamline the process of single audit reviews to gain substantial efficiencies. Regarding late audit report submissions, we will continue to follow the requirements of 2 CFR ?200.339 and Commonwealth Management Directive 325.8. We will continue to work with counties and their independent auditors to obtain any late Single Audit reports. Anticipated Completion Date: 06/30/2023 Contact Person and Title: David Bryan, Manager, ARS; Alexander Matolyak, Director, Division of Audit & Review

Bureau of Operations (BOO): BOO will take the following actions to address the finding: 1. All CAOs and district offices will be reminded of the EBT Coordinators?, alternates?, pinners?, and card makers? responsibilities. The BOO will ensure users in the EBT Card Tracking Database know their responsibilities and segregation of duties and will ensure there is coverage for card pinning until 5:00 pm each business day. Also, reminders to be sent to review the OIM EBT Procedural Manual periodically and when updates occur. This has already taken place on October 7, 2022. 2. All CAOs and district offices will be reminded to maintain adequate security of the EBT cards, card inventory, pinning devices, and ribbons. The EBT office will ensure all offices have two pinning devices and that they are in working order. This has already taken place on October 7, 2022. 3. OIM mandates annual training for EBT personnel to be completed at the beginning of each year. The training includes reviewing the procedures that safeguard access to the EBT systems. Also included are the following: a. Review of roles and responsibilities and who may hold a role b. Card maker and pinner coverage for all business hours c. Proper security for EBT cards and associated items d. Timeframes for submitting changes e. Retention timeframes Training was completed in January 2023. Area managers and staff assistants monitor completion of the training. Bureau of Program Support (BPS)/EBT Project Office: BPS will take the following actions to address the finding: 1. The EBT Project Office will make updates to the EBT Procedures Manual (Manual) and OIM EPPIC EBT Systems Application form (application) as needed. Notification of updates will be sent to CAO staff via email. This is expected to occur by April 30, 2023. 2. The EBT Program office will provide guidelines for the CAOs to follow when reviewing/updating their written internal procedures for EBT security of card mailings. This is expected to occur by April 30, 2023. 3. The EBT Project Officer will start retraining parties that are responsible for the completion of the EBT Headquarters Card Destruction log. This is expected to occur by May 1, 2023. Bureau of Program Evaluation (BPE), Division of Corrective Action (DCA) will take the following actions to address the finding: BPE, DCA conducts EBT Card Security reviews at every CAO and District Office that issues EBT cards. These reviews are completed on a consistent basis, and in the future will be completed annually on a 3-year rotation basis, to ensure the improvement of the execution of documented policies and procedures. BPE/DCA will adjust the review criteria to incorporate any procedural changes implemented in the Electronic Benefit Transfer Handbook. Current rotation schedule spans FFY 2022- FFY 2024. The annual reviews for this cycle started October 2022. Anticipated Completion Date: BOO 1,2, 3- Completed; BPS 1, 2- 04/30/2023; BPS 3- 05/01/2023; BPE- Completed Contact Person and Title: BOO- Jeanette Coulston, Staff Assistant to Director of Bureau of Operations; BPS- Tonya Holloway, Division Director; BPE- Amira S. Milikin, Division Director