Corrective Action Plans

Supportive Housing for Persons With Disabilities ? Assistance Listing No. 14.181 Criteria or Specific Requirement: According to the client's internal control over payroll disbursements, hourly employees must maintain timesheets which are approved and signed by the property manager. Condition: Upon performing testing over payroll disbursements, we noted that there was no approval of the timesheet for one of the payroll disbursements tested. Questioned costs: None Context: The timesheet for 1 out of 5 payroll disbursements tested was not properly approved by the property manager. Cause: Turnover of property manager at the property management company and weaknesses in internal controls over payroll disbursements. Effect: There is no evidence of proper approval of payroll disbursement. Repeat Finding: No Recommendation: We recommend that management strengthen controls over review of payroll. Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Property manager is implementing review prior to payroll disbursement. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: Already implemented as of 7/1/23

Supportive Housing for Persons With Disabilities ? Assistance Listing No. 14.181 Criteria or Specific Requirement: All disbursements from the reserve must be approved by HUD and made for the approved purpose (24 CFR section 891.405). Condition: Upon performing testing over replacement reserve disbursements, we noted that one invoice was included in two different disbursement requests to HUD. Questioned costs: $1,436 Context: One of the invoice tested of $1,436 was included in two different disbursement requests to HUD. Cause: Turnover of property manager at the property management company and weaknesses in internal controls over replacement reserve disbursement. Effect: Disbursements made out of the replacement reserve included an invoice of $1,436 that was already included in previous disbursement request and was reimbursed twice. Repeat Finding: No Recommendation: We recommend that management strengthen controls over review of replacement reserve disbursement requests. Views of Responsible Officials: There is no disagreement with the audit finding. Action taken in response to finding: Property management is increasing staff to properly comply with all regulations. Name of the contact person responsible for corrective action: Angela Westwood, CFO Planned completion date for corrective action plan: Immediate going forward.

2022-001 Comprehensive Opioid, Stimulant, and Substance Abuse Program ? Assistance Listing No. 16.838 Recommendation: We recommend that current time tracking policies and procedures be followed in timecard preparation to document review and subsequent approval including adjustments made by the CFO. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will modify its? Segregation of Duties (BUS 123) policy to include language requiring Supervisory sign-off of manual time charge adjustments that occur after time sheets have been approved as a result of incorrect time sheet submissions. Name(s) of the contact person(s) responsible for corrective action: Roy Fesmire, CFO Planned completion date for corrective action plan: June 30, 2023

Recommendation: We recommend the City implement procedures to ensure that verification documentation for suspension and debarment is maintained to support the City's internal control over compliance. Views of Responsible Officials: There is no disagreement with the audit finding. The City?s Purchasing Policies & Procedures require the grant managing departments to adhere to the Uniform Guidance requirements and maintain procurement documentation related to Federal grants including suspension and debarment. City staff assigned to manage or support federal grant-funded projects will check sam.gov to ensure their vendors are not excluded parties prior to selecting vendors and maintain supporting documentation.

Wabanaki Public Health and Wellness received our FY21 audit in April 2023, which did not allow for the changes to be made in time for FY22. The corrective action plan from FY21 continues to be our course of action and will be fully implementing the following to ensure compliance in FY23. Wabanaki Public Health & Wellness has implemented new positions and transitions of staff on order to increase processes to fall within compliance of all requirements for grants. This includes the reporting aspect financially and programmatically. The Financial Quality and Compliance Manager will be in complete review to verify that all reporting is completed within the correct time frame for each grant. The Grants and Accounting teams will compile a comprehensive list of all grants and dates for all reporting. The Financial Quality and Compliance Manager will maintain the list, file financial reports, and review that program staff has submitted all required reports as needed. Person(s) Responsible: Beth McLean Timing for Implementation: Summer 2023

Wabanaki Public Health and Wellness received our FY21 audit in April 2023, which did not allow for the changes to be made in time for FY22. The corrective action plan from FY21 continues to be our course of action and will be fully implementing the following to ensure compliance in FY23. Wabanaki Public Health & Wellness is committed to having our Single audits completed in time for submission to the clearing house within the appropriate time frame. WPHW has obtained WIPFLI for the next five years and will schedule our audit as early in the season as possible. Wabanaki Public Health & Wellness will be prepared to provide all information that is requested prior to the auditors being within our offices by the designated date in which the items are requested. During the period in which the auditors are within house and the weeks following the Director of Finance and the Financial Quality and Compliance Manager will be available to answer any questions, provide documentation, and details for all requirements for WIPFLI to complete the audit for submission to the clearing house. Person(s) Responsible: Beth McLean Timing for Implementation: Summer 2023

Wabanaki Public Health and Wellness received our FY21 audit in April 2023, which did not allow for the changes to be made in time for FY22. The corrective action plan from FY21 continues to be our course of action and will be fully implementing the following to ensure compliance in FY23. Wabanaki Public Health & Wellness has acquired a new accounting software, go live 2nd quarter of 2023, that allows the separation of access to items, accounts, lists, assets, etc. to be segregated by positions assignments. Each position has different limitations within the software and access to different levels of accounting limits. The new system has approval processes attached to different sections within the recording aspect of different transactions that requires separate staff to approve entries. Wabanaki Public Health & Wellness has also increased the number of staff to help in the separation amongst duties, to strengthen the internal controls within the accounting system and department. The organization is going through a restructure to ensure there are separations of duties, lack of single staff having full access to all items. The Director of Finance and the Financial Quality and Compliance Manager are two of the new positions that have been implemented to help work through the required changes to get the internal control structure and the separations of duties in place. The Financial Quality and Compliance Manager will continue to review processes and validate compliance within the department and suggest changes for processes as they arise within the accounting department. Person(s) Responsible: Beth McLean Timing for Implementation: Summer 2023

The District is in agreement that certain assets were not added to the fixed asset records in a timely manner. These assets were placed into service at the end of the 2021-22 school year but were not included in the District?s fixed asset inventory system until July 2, 2023. Beginning with February 2023 month-end the account clerk will continue with the procedure of reviewing all asset purchases made for the month, however, now the Treasurer, who handles all grants, will now review the monthly listing to ensure all grant purchases are properly included in the correct month and fiscal year. The Assistant Superintendent for Business will be the second level reviewer each month to ensure the asset addition listing each month is complete and accurate.

2022-02 Audit Finding

Portage County respectfully submits the following corrective action plan for the year ended December 31, 2022. Audit period: January 1, 2022 ? December 31, 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 There were no financial statement findings for the year ended December 31, 2022. FINDINGS?FEDERAL AND STATE AWARD PROGRAMS AUDITS U.S. Department of Health and Human Services and Wisconsin Department of Health Services 2022-001 Medical Assistance Program ? Assistance Listing No. 93.778 Wisconsin Medicaid Cost Reporting (WIMCR) ? State ID N/A Recommendation: CLA recommends the County develop and implement a process to require formal review and approval of the WIMCR reports prior to the submission of the report to the state to help ensure that the data reported are accurate and complete. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Staff will implement the County?s existing review and approval process for grants administration for WIMCR program reporting. Name(s) of the contact person(s) responsible for corrective action: Jennifer Jossie Planned completion date for corrective action plan: September 27, 2023 If the granting agencies have questions regarding this plan, please call Jennifer Jossie at (715) 346-1330.

AUDIT FINDINGS Finding Reference Number: 2022-01 Description of Finding: During audit testing several instances of unrecorded receivables, liabilities, and deferred revenues were discovered. Statement of Concurrence or Nonconcurrence: The Agency agrees with this finding. Corrective Action: NHCOG has made arrangements to retain an outside accounting professional to verify the proper internal controls are being implemented before this Fiscal Year end and is considering adding staff with an accounting background as part of the long-term plan. Name of Contact Person: Robert Phillips, Executive Director Projected Completion Date: June 30, 2023 Finding Reference Number: 2022-02 Description of Finding: Weakened internal controls over grant reporting resulted in delays in the billing for the transit planning and RITS programs. Statement of Concurrence or Nonconcurrence: The Agency agrees with this finding. Corrective Action: NHCOG acknowledges that there were delays due to staff turnover at the agency as well as at the state funding source and with certain RITS service providers. It is anticipated that these processes will improve with time and full staffing levels at each agency. Name of Contact Person: Robert Phillips, Executive Director Projected Completion Date: June 30, 2023 Finding Reference Number: 2022-03 Description of Finding: Form DE-2017 was not submitted within 90 days of the fiscal year-end. Statement of Concurrence or Nonconcurrence: The Agency agrees with this finding. Corrective Action: Form OPM-DE-2017 will be submitted moving forward. New staff was unaware of the filing requirement. Name of Contact Person: Robert Phillips, Executive Director Projected Completion Date: June 30, 2023 Finding Reference Number: 2022-04 Description of Finding: Grant contract for the period October 1, 2021 through June 30, 2022 could not be located. Statement of Concurrence or Nonconcurrence: The Agency agrees with this finding. Corrective Action: NHCOG will work with the state to be sure that all contracts are available for review at both entities. Name of Contact Person: Robert Phillips, Executive Director Projected Completion Date: June 30, 2023 Finding Reference Number: 2022-05 Description of Finding: EDA Cares funds of $9,500 were spent after the grant period had ended. Statement of Concurrence or Nonconcurrence: The Agency agrees with this finding. Corrective Action: NHCOG acknowledged the error and performed the necessary corrections promptly as soon as it was discovered. Name of Contact Person: Robert Phillips, Executive Director Projected Completion Date: June 30, 2023 There are no questioned costs. If the office of Policy and Management has questions regarding this Plan, please call myself at 860-491-9884 x104. Sincerely yours, Robert Phillips Executive Director

Finding: 2022-001: Reporting ? Significant Deficiency in Internal Control over Compliance Corrective Action Plan: Management agrees with the finding related to the timing of posting certain quarterly information to the College?s website within 10 days of the end of the quarter in which Education Stabilization Funds were expended. To address this issue, management has instituted a reconciliation of the award amount to the reported expenditures and implemented regular checks of the College?s COVID-19 response website to ensure reports continue to be posted in a timely manner. The College has now expended all Education Stabilization Funds, so we do not anticipate any additional quarterly reports needing to be posted on the College?s website. Contact Person Responsible for Corrective Action: Vice President of Business, Chief Financial Officer Erin Watkins, and Director of Finance Jennifer Perez have implemented the corrective action plan. Anticipated Completion Date: Corrective action was completed by October 2022.

2022-002. Finding: Compliance Findings ? Reporting Response: The Business Manager is the contact person at this entity responsible for the corrective action plan for this comment. The COVID pandemic has caused problems for our School District. Due at approximately the same time were the extended audit for June 30, 2022, the annual report for June 30, 2023, and the proposed budget for the 2023-2024 school year. The late filing was caused by multiple financial processes being completed simultaneously.

2022-02 Audit Finding

Federal Award Finding Internal Control Over Compliance / Compliance Finding ? Significant Deficiency 2022-002 East Georgia Healthcare Center (EGHC) acknowledges the discrepancies between key line items on the Period 1 Provider Relief Fund (PRF) portal submission and underlying supporting documentation. As a result of the difficulties described in financial statement finding 2022-001, there were delays in revenue billings and financial reporting, which impacted monthly net revenues from patients used in the Period 1 lost revenue calculation. Subsequent to the Period 1 PRF portal submission, EGHC recalculated monthly net revenues from patients based on updated actual amounts. Calculated lost revenues using the updated monthly amounts were less than lost revenues reported per the Period 1 PRF portal submission. However, EGHC has identified additional expenditures attributable to COVID-19, which were incurred during the period of January 1, 2020 through June 30, 2021, that offset the difference in lost revenues per the Period 1 PRF submission and lost revenues calculated using updated actual net revenues from patients. Based on this, EGHC believes that any risk to the program would be mitigated through the identification of additional eligible expenditures for Period 1. EGHC intends to correct the lost revenues and expenditures reported for Period 1 on the Period 4 PRF portal submission, which is due March 31, 2023. Sincerely, Jill Sorrells Chief Financial Officer

Planned Corrective Action The district Food Service Director will verify and print supporting documentation to prove system-generated reports reconcile to the CRRS System after data entry is completed. The Food Service Director will initial and date the reports upon completing and verifying the reconciliation. Anticipated Completion Date: 3/1/2023 Responsible Contact Person: Food Service Director

Finding 2022-003: Internal Controls Over Financial and Performance Reporting ? Significant Deficiency Management Response and Planned Corrective Action This finding relates to the absence of a signature and date indicating a management review before submission for reimbursement as evidence of an internal control. Management concurs that there was no signature and date reviewed for submissions related to the Disaster Grants ? Public Assistance program. Management will implement a process where all submissions to federal agencies will be signed and dated prior to submission as an indication of internal control over the approval process.

Finding 2022-004: Federal Funding Accountability and Transparency Act for Housing Opportunities for Persons with AIDs Program ? Significant Deficiency Management Response and Planned Corrective Action Management agrees that the Federal Funding Accountability and Transparency Act (FFATA) report for the Housing Opportunities for Persons with AIDs Program for three sub-awards was not submitted by the last day of the month following the month in which the sub-award was made, and three of the obligation dates reported were incorrect. The FFATA report was prepared and filed by the Neighborhood Services Administrator. Management will implement a process where Grant Coordinators will prepare the report and the Grant Administrator will review the information for accuracy and input the data into the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). The Neighborhood Services Administrator will review the report and file in a timely manner.

Finding 2022-005: Federal Funding Accountability and Transparency Act for Community Development Block Grant Program ? Significant Deficiency Management Response and Planned Corrective Action Management agrees that the Federal Funding Accountability and Transparency Act (FFATA) report for Community Development Block Grant Program for five sub-awards was not submitted by the last day of the month following the month in which the sub-award was made, and one of the obligation dates reported was incorrect. The FFATA report was prepared and filed by the Neighborhood Services Administrator. Management will implement a process where Grant Coordinators will prepare the report and the Grant Administrator will review the information for accuracy and input the data into the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). The Neighborhood Services Administrator will review the report and file in a timely manner. Responsible Personnel Gary Ameling, Chief Financial Officer

View of Responsible Officials 1. We concur. The Provider enrollment unit (PEU) is currently working on revalidations not completed and have a plan to deposition those providers while ensuring minimal disruption to member services and protecting limited provider networks disciplines such as the mental health network. I, the PEU administrator have been conducting biweekly meetings with Conduent and our business systems analyst to develop a plan and a systematic approach to revalidate all providers in the future. I am currently drafting a policy and procedure memo that will outline the new process for revalidations so that revalidations will be timely and complete in the future. Once the new process is implemented, I intend to review revalidations with Conduent at our biweekly provider enrollment meetings to ensure the revalidation process is conducted in a timely fashion and the implemented process for revalidations is working in that all revalidations are performed timely. As for the past due revalidations, the PEU anticipates all past due provider revalidations, prior to the PHE, to be either completed or be terminated by the beginning of March 2023. 2. We partially agree. The attestation signed in 2012 does not have an expiration and there is no Federal regulation or State law that requires this to be renewed, however, based on the finding last year, the Office of Medicaid Services did a new attestation in 2022. The 2022 attestation also does not have an end date and is not required to be renewed at any time. The attestation ends when the agreement is terminated by either parties. Anticipated Completion Date: March 2023 Contact Person: Stephanie Aulis

View of Responsible Officials The Department partially concurs as follows: The Department?s position is that it maintains compliance with the Federal Funding Accountability and Transparency Act (FFATA) (Pub. L. No. 109-282), as amended by Section 6202 of Public Law 110-252, hereafter referred as the ?Transparency Act? that are codified in 2 CFR Part 170, recipients (i.e., direct recipients) of grants or cooperative agreements are required to report first-tier subawards of $30,000 or more to the Federal Funding Accountability and Transparency Act Subaward Reporting System (FSRS). The Department agrees that during the year ended June 30, 2022, not all of the tested FFATA reports were deemed complete and accurate due to internal control considerations. The Department will review current practices regarding the internal control of financial information included in the G&C PDF?s which are the basis of the FFATA reporting with the objective of accurately reporting the specific amounts of Federal Funding content by FAIN so as to facilitate the accurate and timely reporting of FFATA in accordance with the Act. Anticipated Completion Date: September 30, 2023 Contact Person: PJ Nadeau, Administrator

View of Responsible Officials We concur. The Department has been reviewing and second reviewing all required monthly financial reports and maintaining documentation since January 2022. We believe this current control in place allows us to remain in compliance with all requirements. Anticipated Completion Date: March 2, 2023 Contact Person: Shelley Swanson, DPHS Finance Director

2022-003 NSLDS Reporting Recommendation: We recommend the University review its reporting procedures to ensure that students? statuses are accurately reported to NSLDS as required by regulations. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: please see below Name(s) of the contact person(s) responsible for corrective action: Elizabeth Vestal, Registrar. Planned completion date for corrective action plan: December 31, 2022 with continued auditing after. Four areas of deficiency have been identified within our current enrollment reporting process. Specifically, 1) the university did not correct errors within ten days, 2) the program begin date reported to NSLDS (National Student Loan Data System) does not match the university?s records, 3) the student?s program enrollment effective date is incorrectly reported to NSLDS and 4) status changes were not certified and/or received within sixty days. In response to your findings, the Registrar?s Office has created a plan of action to remedy the errors. The enrollment reporting process has new leadership at the university. The findings from the new audit team will be corrected. The corrections will require the university to change current behaviors, practices, and reports. Findings two and three are connected to the program start date entered into Colleague. Currently, when processing a program add or change in Colleague (student information system), the program start date defaults to the first day of the month of the start of the term. In the past admissions and advising have been instructed to enter the upcoming term date as the program start date in the SACP (Student Academic Program) screen of Colleague. Unfortunately, this is not being done consistently and several teams have reverted to using the default date and the issue was not identified prior to reporting. The following outlines the proposed corrective action plan: 1) New and re-entry/re-admit students, program changes, or change of residency a. Effective for student programs starting in Fall 2 2022, the program start date in Colleague will match the start date of the upcoming term or end date of prior term. The operator will manually correct the default date to mirror the first day of the start term or end date of prior term in Colleague. i. If there is a potential issue with the date of the upcoming term, the Registrar?s Office must be consulted prior to committing to an alternate date. 2) Active continuing students a. Phase 1: The Fall 1 2022 census report will be used to generate a list of all currently active students. Each student will be manually reviewed to verify the program effective start date reflects the start of term at the university or start of term for the next declared program/major. Although the start date of a program change is not required to match the start of term for enrollment reporting purposes, this will eliminate processing confusion and increase consistency. i. The first phase of corrections will be completed by October 24, 2022. b. Phase 2: Prior census reports will be used to capture students who had been active in terms from Summer 1 2021 to Fall 1 2022. The program effective start dates will be reviewed and corrected as needed. i. The second phase of corrections will be completed by December 31, 2022. 3) Communication a. Issue a Registrar Communication memorandum (RegCom) outlining the new expectations for assigning the program effective start date, auditing schedule, and implications of errors to the following within the university, by October 24, 2022. i. Registrar team ii. Admissions operations iii. Deans, Chairs, and Program Directors iv. Campus success coaches, faculty advisors, and coordinators v. Center directors and staff 4) Inactive students (have not attended since Summer 1 2021) a. The program effective start date of students who have not been active at the university since the Summer 1 2021 term will be reviewed and updated upon re-entry/re-admit to the university (See bullet 1 above). 5) Report/Audit a. Coordinate with the Department of Information Technology (DoIT) to create a SQL report to pull student information from Colleague, including the student?s start term and declared program effective start date. b. The Registrar?s Office will audit the report weekly to ensure all dates are compliant and accurate prior to generating the enrollment file. 6) Colleague functionality a. Explore the possibility of amending the default date assigned by Colleague. i. This is restricted by the capabilities of the SIS. If unable to amend, we would continue with manual process noted above. Findings one and four relate to the timing of file submission and correcting roster errors. The Registrar will review the university?s reporting procedures and schedule to ensure that student statuses are accurately reported through the servicer to NSLDS within sixty days and errors are corrected within ten days. To do so, the Registrar will: 1) Establish an annual schedule to report student statuses every thirty to sixty days. a. Attention will be given to term dates, withdraw deadlines, as well as weekends and calendar holidays. 2) Create a sub-schedule of timing for correcting errors. This schedule should account for days necessary for the servicer and NSLDS to process the data. 3) Audit the SCHER5 and other reports weekly to ensure any remaining errors are corrected within ten days. By taking the above actions, Saint Leo will have processes in place to establish and maintain procedures to reasonably achieve compliance with NSLDS regulations providing timely and accurate data and audit the effectiveness of our data collection and reporting procedures. The university, specifically the Registrar?s Office, is committed to submitting complete, accurate, and timely enrollment data for Saint Leo University students.

2022-002 Return to Title IV Recommendation: We recommend the University review the R2T4 requirements and implement procedures to ensure the R2T4 calculations are using the correct amount of term days and are completed accurately. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Report is being created that will allow staff to compare R2T4 manual data entries against source data. Discrepancies will be researched and corrected within 5 business days. Report will be generated weekly and reviewed by the manager over this area. Name(s) of the contact person(s) responsible for corrective action: Brenda Clark, Director of Financial aid Planned completion date for corrective action plan: Implementation of new quality control R2T4 report planned for October 24, 2022.

Finding Number: 2022-005 Program: COVID-19 ? Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) Award Number and Year: ELC08CHW (3/1/2021 ? 2/28/2022) Compliance Requirement: Reporting Type of Finding: Significant Deficiency in Internal Control Over Compliance, Other Matters Criteria or specific requirement: Compliance: Per Maryland Department of Health, subgrantees are required to submit Monthly Status Reports by the 10th of the month they are reporting on. Control: Per 2 CFR section 200.303(a), a non-Federal entity must: Establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should comply with guidance in ?Standards for Internal Control in the Federal Government? issued by the Comptroller General of the United States or the ?Internal Control Integrated Framework?, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition: Prince George?s County (County) did not file Monthly Status Reports in a timely manner. Cause: The County?s procedures and controls were not sufficient to ensure that Monthly Status Reports were filed timely. Resolution: The Health Department will review and enhance internal controls and procedures to ensure that Monthly Status Reports are filed timely. Specifically, the Health Department will update the routing reporting deliverables matrix that documents all grant reporting requirements and frequency to ensure we are in compliance with the reporting requirements. In addition, we will update our internal grant guidance document to include all control requirements per 2 CFR section 200.303, by adding language to establish and maintain effective internal controls over the Federal award. We will hold a meeting with the fiscal team once the internal grant guidance document is updated to ensure compliance with guidance in standards for internal control in the Federal Government. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Responsible Party: Sezelle Gabriel Banwaree, Associate Director of Administration Anticipated corrective action plan completion date: The Health Department will continue to follow the established procedures and reporting requirements for a non-Federal entity to ensure we comply with the monthly status report requirements by the 10th of the month we are reporting on. We will have our reporting calendar and grant requirements document updated by no later than Friday, April 28, 2023.