Corrective Action Plans

Corrective Action Plan: In September 2022, DSHA implemented new processes for preparing and submitting ERA reports to U.S. Treasury. A third party technical assistance provider now has access to the UST Reporting portal, and coordinates with DSHA program staff to collect data to prepare report submissions. After reporting fields have been populated in the UST Portal, the DSHA Director of Policy & Planning reviews, certifies, and submits reports to UST. DSHA is coordinating with this technical assistance provider to ensure that a record of reporting information is retained after reports are submitted. Responsible Official: Devon Manning, Director of Policy & Planning and Brian Rossello, Director of Housing Finance Completion Date: September 2022

Federal Awards Finding 2022-007 - Emergency Rental Assistance Eligibility Corrective Action Plan: Please see responses to 2022-002, 2022-004, and 2022-005. Responsible Official: Devon Manning, Director of Policy & Planning and Brian Rossello, Director of Housing Finance Completion Date: August 2021

Federal Awards Finding 2022-006 - Emergency Rental Assistance Eligibility Corrective Action Plan: Please see responses to 2022-002, 2022-004, and 2022-005. Responsible Official: Devon Manning, Director of Policy & Planning and Brian Rossello, Director of Housing Finance Completion Date: August 2021 Financial Statement Finding 2022-002 - Internal Control Over Compliance - United States Emergency Rental Assistance Program Corrective Action Plan: DSHA has implemented a Corrective Action Plan which it believes fully addresses the internal control weaknesses identified in connection with the audit finding of a material weakness related to DSHA?s operation of the Emergency Rental Assistance (?ERA?) program. The Corrective Action Plan is comprised of three key elements: 1. Implementation of a new software system that fully addresses certain process issues encountered with its existing software application. 2. Implementation of new process workflows and approvals performed by DSHA personnel to ensure proper approval of case applications and payment of approved applications to proper vendors. 3. Engaging an external consultant to analyze, verify and remediate, as required, applications processed in the predecessor software system. Each of these three elements is further discussed below. In August 2021, DSHA implemented a new software application to accept and process applications for the ERA program and replace its existing application. DSHA implemented this system as a means to correct and resolve the issues it was experiencing with respect to timely and accurate payment processing. The new system included significant improvements in workflow related to payment processing and account verification, as well as other needed program features. With the new software application, one of the root causes of DSHA?s application payment issues was immediately addressed, by eliminating the need to manually upload vendor payment information from its predecessor application to DSHA?s accounting system for payment. The prior manual upload process resulted in various vendor payment issues and erroneous payments. The new software application is a completely self-contained application, with workflow approvals that span from application submittal and approval to vendor payment. Each week all approved applications are automatically batched and sent to DSHA for approval prior to payment. This workflow has resolved previous issues where payments were not made timely for approved applications. The new software application incorporates significant improvements to payment processing and account verification. As mentioned above, there is no need to transfer or upload data between new software application and the accounting system to effect payments of approved applications. The new software application includes a verification process whereby the vendor ACH information is verified by a ?penny test? or small deposit that the user must verify. ACH payments can only be made to accounts that are verified. Once payments are made through new software application, batch details are imported to the accounting software via a custom interface for accounting system transaction reporting. Implementation of New Process Workflows, Approvals and Verifications by DSHA Coupled with the new software application implementation, DSHA implemented updated ERA Program Guidelines and new internal policy and process manuals to ensure its internal controls and processes appropriately addressed the compliance requirements of the ERA program and to ensure properly approved applications are paid to proper vendors. All cases in Approved Status are batched each week by the new software application and sent to DSHA for approval. DSHA reviews each of the approved applications within the batch and approves the batch once verified. At that point, requested funds are wired and payments issued by the new software application. This process has resolved previous instances of non-payment of approved cases. DSHA has developed new Case Auditor and Case Supervisor Process Guides and Checklists, which now standardize the processes used to review, verify and approve applications prior to payment. The new software application case management workflow requires separate Case Auditor and Case Supervisor verification of program requirements and payments prior to approval and payment of an application. Remediation of Prior Case Applications Processed in the predecessor application DSHA has engaged a third-party external consultant to assist it in ensuring that the applications processed in the predecessor application system resulted in payments to appropriate vendors for proper, compliant applications. The objective of this assessment is to identify any applications processed within predecessor application that resulted in either over or under payment to the vendor recipient. Once identified, these over and/or under payments will be remediated. These action plans have been implemented beginning August 2021 for the 2022 Fiscal Year and will remain in effect going forward. Responsible Official: Marlena Gibson, Director of Policy and Planning. Responsible Official: Marlena Gibson, Director of Policy and Planning. Financial Statement Finding 2022-004 ? Internal Control Over Compliance ? United States Emergency Rental Assistance Program Corrective Action Plan: DSHA will take these recommendations under advisement, and review program policies and procedures to ensure they are in accordance with statutory requirements. DSHA will ensure that staff responsible for processing DEHAP applications are training effectively in how to interpret and apply program policies and procedures, and will clearly communicate the expectation that review staff adhere to program policies and procedures consistently. DSHA would like to request clarification on Belfint's interpretation of the statutory requirement around security deposits. To our knowledge, UST has suggested applying a limit of one month's rent as guidance, but has not made this an actual requirement of the federal Emergency Rental Assistance Program. Responsible Official: Marlena Gibson, Director of Policy and Planning.

COUNTY OF BERNALILLO CORRECTIVE ACTION PLAN YEAR ENDED JUNE 30, 2022 United States Department of Housing and Urban Development The County of Bernalillo respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 ? June 30, 2022 The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS UNITED STATES DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT 2022-002 Section 8 Housing Choice Vouchers ? Assistance Listing Number 14.871 Recommendation: The County continue to review internal processes and policies to better ensure compliance with HUD requirements for participant eligibility. Staff should be trained to better ensure consistency in program participant file documentation and compliance with documentation required by HUD. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: All program staff will attend a HUD approved HCV and rent calculation training to ensure compliance with all HUD regulations including EIV and rent calculations. In addition, staff will be trained on our internal checklist to ensure consistency of documentation retained in each client?s file. Name(s) of the contact person(s) responsible for corrective action: Betty Valdez, Housing Director Planned completion date for corrective action plan: June 2023 If the Department of Housing and Urban Development has questions regarding this plan, please call Betty Valdez, Housing Director, at 505-314-0235.

FINDING 2022-001 (Auditor Assigned Reference Number) Contact Person Responsible for Corrective Action: Weston Reed Contact Phone Number: 765-456-7455 Views of Responsible Official: We concur with the finding. Description of Corrective Action Plan: 1. Starting with the 2023 June quarter-end P&E report which is due in July 31, 2023 City will have another employee review and sign off on the report prior to final submission on line. Anticipated Completion Date: July 31, 2023

2022-004 Eligibility ? Assistance Listing No. 84.063 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Policy and Procedures of reporting deadlines and requires has been put into action by the director of financial aid. Name(s) of the contact person(s) responsible for corrective action: Grant Pollard, Director of Financial Aid Planned completion date for corrective action plan: 11/1/2022

2022-009 Eligibility ? Assistance Listing No. 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Policy and Procedures of reporting deadlines and requires has been put into action by the director of financial aid. Name(s) of the contact person(s) responsible for corrective action: Grant Pollard, Director of Financial Aid Planned completion date for corrective action plan: 11/1/2022

2022-008 Inadequate Schedule of Federal Expenditures Reporting ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: CFO prepared the FY 21 SEFA in advance of the 3/31/2022 Single Audit deadline. CFO will prepare the FY 22 SEFA in advance of the 3/31/2023 Single Audit deadline. Name(s) of the contact person(s) responsible for corrective action: Ashley Chancellor, CFO Planned completion date for corrective action plan: 11/1/2022

2022-007 Special Tests and Provisions ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. After year end, the College engaged CLA to assist with the GLBA process for the next fiscal year. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: College IT department is currently working with outside consultants to perform a risk assessment. Name(s) of the contact person(s) responsible for corrective action: Ashley Chancellor, CFO Planned completion date for corrective action plan: 11/1/2022

2022-006 Special Tests and Provisions ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The director of financial aid works with the third-party servicer to ensure accurate student programs and program beginning dates reported to NSLDS. The financial aid office cross-references program information within the student information system. Name(s) of the contact person(s) responsible for corrective action: Grant Pollard, Director of Financial Aid Planned completion date for corrective action plan: 11/1/2022

2022-005 Special Tests and Provisions ? Assistance Listing No. 84.063, 84.268 Recommendation: We recommend the College design controls to ensure an adequate review process is in place to ensure compliance with reporting requirements. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The director of financial aid works with the third-party servicer to ensure accurate and timely enrollment updates to NSLDS. Name(s) of the contact person(s) responsible for corrective action: Grant Pollard, Director of Financial Aid Planned completion date for corrective action plan: 11/1/2022

Federal Audit Clearinghouse: CommQuest Services, Inc. and Subsidiaries. respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 1, 2021 through June 30, 2022. The findings from the schedule of findings and questioned costs are discussed below. The findings are numbered consistently with the numbers assigned in the schedule. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS Department of Health and Human Services 2022-001 Provider Relief Funds ? Assistance Listing No. 93.498 Recommendation: CommQuest Services, Inc. and subsidiaries management request that HHS re-open the portal so as to re-submit based on the lost revenue calculation versus based on the original reporting method which used expenditures as a basis. If unable to re-open the portal, verify for next submission to HHS, if applicable, that the organization submits report based on the lost revenue calculation. It was also recommended that CommQuest Services, Inc. and subsidiaries management review this reporting submission. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management agreed with the above finding and attempted to re-open the HHS portal to accurately report based on the lost revenue calculation, but given the timing of the request, were denied by HHS. Name(s) of the contact person(s) responsible for corrective action: Melissa Hoch, CFO Planned completion date for corrective action plan: October 2022 If the Federal Audit Clearinghouse or Department of Health and Human Services has questions regarding this plan, please call Melissa Hoch at 330-445-2672.

2022-001 Improve Controls and Compliance over Reporting PLANNED ACTION: The County has reviewed the finding and will submit the next annual report in accordance with the most recent edition of the Project and Expenditure Report User Guide, dated 29 December 2022. PLANNED IMPLEMENTATION DATE OF CORRECTIVE ACTION: April 30, 2023 RESPONSIBLE INDIVIDUAL: Derek Ferland, County Administrator

Finding 2022-004, Significant Deficiency and Non-Material Non-Compliance - Reporting Corrective Action Plan: Goal: To ensure US Treasury reports are submitted timely and accurately, the County will log into the US Treasury website to download and save copies of previously submitted ERAP reports. Plan: The County will retain a repository with internally reviewed and uploaded reports. Performance Improvement Strategies: 1. Prior to March 10, 2023, reports that were submitted in the US Treasury website related to ERAP were not able to be saved/retained. 2. Leadership will log into the US Treasury website and download all prior reports submitted + will continue to download and save reports submitted henceforth. 3. All staff who participate in the submission of reports will sign and date the submitted report to verify internal review of information submitted. 4. Copies of reports will be stored in the shared Teams Channel for ERAP. 5. Supporting reports/documentation and meetings related to US Treasury reports will be retained via printed/signed copies. Responsible Parties: Mia Stockton, Economic Services Division Director Timeframes: Prior reports submitted will be downloaded and retained no later than 3/17/2023. Future reports/updates to reports will be retained upon submission.

Finding 2022-003, Significant Deficiency - Eligibility Corrective Action Plan: Goal: To ensure necessary Medicaid corrections are made by caseworkers in a timely manner and verified as completed by Medicaid management and/or Quality Assurance staff. Plan: The County will include a due date to the auditing tool so that correction tasks request can be tracked and monitored for completion and accurateness. Eligibility errors will be given five business days to be completed by workers and Internal Controls will be completed in 10 business days as they may require streamlining or revamping of internal processes. Performance Improvement Strategies: 1. Training will be given to supervisors, lead workers, and QA staff on proper usage and monitoring of due date requirements added to the audit tool. 2. Copies of reports will be stored in the shared Teams Channel for Medicaid Services. Responsible Parties: Marissa D. Adams, Medicaid Services Division Director Timeframes: Training for the usage of an audit tool is to be held no later than June 30, 2023, and usage of to begin immediately after is completed.

Corrective Action Plan Finding: 2022-002-SEMAP and Quality Control Needs Better Documentation Condition: (a)-for the move-ins tested, the move-ins were listed on the waiting list. However, none of the move-ins in our sample were on the top of the waiting list. Often, there were several applicants listed above the move-in participant., without an explanation. There should be notes for why the above applicants listed were not moved in before the one of our sample. Some of the typical reasons we often see is ?voucher expired?, ?no longer interested?, or ?unable to contact.? Most computerized waiting lists allow the Authority to list in ?notes? the reason why applicant was not moved in. Or, manual explanations can be added on the waiting list. The Admin Plan states there are no local preferences. So, giving points for preferences is not a reason that should be listed for early admittance. (b)-The waiting list was tested. However, per the federal regulations, half the sample should start with the waiting list and review the disposition. The other half should start with the current year admits and work back from the waiting list. It appears the sample was not pulled in the above manner. Regarding the definition of the total universe, this has never been exactly defined. If the Authority has received direction from HUD about the definition of the universe, the Authority should follow that direction. (c)-It appears the waiting list was not purged annually, in accordance with the Admin Plan. Corrective Action Planned: We will comply with the auditor?s recommendation. Person responsible for corrective action: Mary Grace Saenz, Executive Director Telephone: (915) 886-4650 Housing Authority of the Town of Anthony, Texas Fax: (915) 886-2296 1007 Franklin Anthony, TX 79821 Anticipated Completion Date: September 30, 2023

Finding #2022-002 ? Significant Deficiency Applicable federal programs: U. S. Department of Justice Assistance Listing #16.575 Passed through Office of the Governor, Criminal Justice Division Crime Victim Assistance Contract #: 3521203 Contract year: 10/01/21 ? 09/30/22 Crime Victim Assistance Contract #?s: 4219601 and 4219602 Contract years: 10/01/21 ? 09/30/22 and 10/01/22 ? 09/30/23 Recommendation: Provide additional staff training to ensure that HAWC?s internal control procedures that require review of client files are followed. Planned corrective action: Management will review and ensure compliance with policies and procedures regarding the review and approval of client files to ensure that reviews are completed. Responsible officer: Chief Quality Officer Estimated completion date: August 20, 2023

Finding #2022-003 ? Significant Deficiency and Other Noncompliance Applicable federal programs: U. S. Department of Housing and Urban Development Assistance Listing #14.231 Passed through Child Care Council of Greater Houston Emergency Solutions Grant Program Contract #: 460-001-3805 Contract years: 05/01/21 ? 03/31/22 and 04/01/22 ? 03/31/23 Assistance Listing #14.231 Passed through Harris County Community Services Department (Office of Housing and Community Development) Emergency Solutions Grant Program Contract #?s: 2021-0033g and 2022-008f Contract years: 03/01/21 ? 02/28/22 and 03/01/22 ? 02/28/23 Assistance Listing #14.231 Passed through Texas Department of Housing and Community Affairs Emergency Solutions Grant Program Contract #?s: 42217000046 and 42227000044 Contract years: 11/01/21 ? 10/31/22 and 11/01/22 ? 10/31/23 Assistance Listing #14.231 Passed through Texas Department of Housing and Community Affairs COVID-19 ? Emergency Solutions Grant Program Contract #: 44207000047 Contract year: 01/14/21 ? 06/30/23 Assistance Listing #14.231 Passed through Texas Department of Housing and Community Affairs Emergency Solutions Grant Program Contract #: 20220000030 Contract year: 03/31/22 ? 03/31/24 Assistance Listing #14.267 Direct Funding Continuum of Care Program Contract #?s: TX0179L6E002013 and TX0179L6E002114 Contract years: 10/01/21 ? 09/30/22 and 10/01/22 ? 09/30/23 Assistance Listing #14.267 Passed through Harris County Domestic Violence Coordinating Council Continuum of Care Program Contract #?s: TX0538D6E002106 and TX0538D6E002002 Contract years: 08/01/22 ? 07/31/23 and 08/01/21 ? 07/31/22 Applicable state program: Office of the Attorney General ? State of Texas Sexual Assault Prevention and Crisis Services Contract #?s: 2217883 and C-00112 Contract years: 09/01/21 ? 08/31/22 and 09/01/22 ? 08/31/23 Recommendation: Emphasize adherence to established policies and procedures to ensure procurement is performed according to the procurement policy, and that proper procurement documentation is maintained. Planned corrective action: Management will review and ensure compliance with policies and procedures regarding procurement. Responsible officer: Chief Financial Officer Estimated completion date: June 30, 2023

Subject: 2022-002 Coronavirus State and Local Fiscal Recovery Funds ? Reporting Federal Agency: Department of the Treasury Federal Program: Coronavirus State and Local Fiscal Recovery Funds Assistance Listing Number: 21.027 Compliance Requirement: Reporting Audit Finding: Significant Deficiency Recommendation: The Auditor recommends the City implement procedures to ensure reports are being reviewed by an individual or third-party familiar with the grant prior to their submission, including reconciliation of the report to the general ledger system. Planned Corrective Actions: The City agrees with the recommendation and plans to implement the recommendation during 2023.

2022-001 Internal Controls over Payroll Cost Allocation Type of Finding: Significant Deficiency in Internal Control over Financial Reporting Response: Adult Care Management, Inc. (ACMI) agrees with the finding of Taylor Roth & Company, PLLC, in the fiscal year 2022 Single Audit (SEFA) that the established internal controls over payroll cost allocation did not operate as intended to ensure appropriate allocation of payroll costs across all programs in the five (5) of the twenty-four sampled payroll periods for one (1) individual. Action: Effective March 10, 2023, the internal control practices of ACMI will be strengthened to support a review system able to prevent and/or detect and correct errors in a timely manner to ensure payroll costs are accurate, allowable, and properly allocated. Specifically, management?s monthly review of all cost allocations will include a review of the data entry hours from payroll timesheets into the payroll allocation spreadsheet of no less than 10% of total reporting employees, with a priority focus on employees reporting time to more than one program / cost center.

Finding 2022-002: Significant Deficiency - COVID-19 Education Stabilization Fund, Higher Education Emergency Relief Funds Reporting Program: COVID-19 Education Stabilization Fund, Higher Education Emergency Relief Funds Assistance Listing Number: 84.425E and 84.425F Federal Agency: U.S. Department of Education Federal Award Identification Number: P425E201560 and P425F201058 Federal Award Year: June 30, 2022 Repeat Finding: 2021-002 Criteria: The U.S. Department of Education (the Department) has issued guidance for the Education Stabilization Funds (ESF) Higher Education Emergency Relief Funds (HEERF) for quarterly reporting for all sections (a)(1), (a)(2), (a)(3) and (a)(4) that requires that institutions to prepare a report for each quarter for funds t11at are drawn down and disbursed/spent. The reports are to be posted on the institution's website within 10 days of the calendar quarter end. Additionally, institutions are required to prepare an annual report and submit to the Department summarizing the uses of the HEERF funds for the calendar year. Condition/Context: Incorrect data was reported in two institutional portion quarterly reports and the annual report. Three student portion quarterly reports were not posted to the University's website. One student portion quarterly report and two institution quarterly reports were posted to the University's website after the 10 days after quarter end requirement. The annual report was also submitted late. The auditor selected a sample of one student portion quarterly report and two institutional portion quarterly reports in addition to the annual report. The sample was not a statistically valid sample. Questioned Costs: Not applicable. Cause: The University's internal control surrounding preparing, reviewing and posting the reports did not deter or prevent errors in the reporting or late or missing posting of the quarterly reports to the University's website. The University noted there was confusion and misunderstanding on the HEERF reporting requirements including deadlines and whether reports were to be cumulative or not. Effect: The University had HEERF quarterly reporting on its website and annual reporting to the Department that were missing and/or incorrect and/or late. Recommendation: The University should ensure it keeps up to date on the Department's HEERF guidance and ensure that reporting is done accurately and timely. Management's Response: The University concurs with the finding. The University experienced challenges during COVID limiting the availability of resources to review and adequately analyze the reporting guidance as it developed. As a result, there were some misunderstanding of the requirements as they changed over time. Tl1e University continued to experience challenges with staffing in 2022 that limited the availability of resources to address the past and current reporting issues. The University will assign more resources to address all reporting issues including updating the website, revising and resubmitting past reports, and submitting missing reports. In accordance with the corrective action plan, additional resources have been allocated to review all reporting requirements, revise existing reports as needed and submit missing reports. Anticipated completion date: December 31, 2023 Contact: Mary Woolfolk (Controller) at 949-214-3123

Concordia University Irvine An Educational Institution of The Luther Church - Missouri Synod Schedule of Findings and Questioned Costs June 30, 2022 Finding 2022-001: Significant Deficiency - Return of Title IV Funds Program: Federal Direct Student Loans Assistance Listing Number: 84.268 Federal Agency: U.S. Department of Education Federal Award Identification Number: P268K223683 Federal Award Year: June 30, 2022 Criteria: 34 CFR 668.22 requires that when a recipient of Title IV grant or loan assistance withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must determine the amount of Title IV grant or loan assistance that the student earned as of the student's withdrawal date in accordance with Federal regulations and return the unearned portion of the grant or loan funds to the Title IV programs as soon as possible but no later than 45 days after the withdrawal date. Condition/Context: In a sample of 15 students that withdrew during the fiscal year, the University did not perform the required return to Title IV calculations for four students who completed less than 49% of the payment period. For one additional student, a Title IV calculation was prepared, however the calculation was incorrect and an incorrect amount was returned. The sample was not a statistically valid sample. Cause: The University incorrectly interpreted the period of enrollment to be the one module and not the entire payment period for the withdrawal exemption for successful completion of 49% or more. The University's interpretation was made in May 2021 and therefore impacts students in the 21-22 award year as well as in the 22-23 award year through March 1, 2023 when the error in interpretation was confirmed. Effect: The University incorrectly calculated students as having completed more than 49% and therefore did not perform R2T4 calculations or return unearned loan funds to the Department. Additionally, some R2T4 calculations were incorrect based on the calculation using only the module not the days in the payment period. Questioned costs: Total questioned costs were $10,819 of Direct Student Loan funds. Recommendation: It is recommended that the University review interpretations, policies and procedures in place for withdrawals and R2T4 calculations to ensure that correct dates and institutional charges are being used. Management's Response: Upon discovery of the errors, the University reviewed the population of withdrawn students where the dates for one module were used versus the payment period. The University performed the additional or revised Title IV calculations for five students and returned additional funds. The $10,819 reported as questioned costs identified by the auditors has also been returned. The university will also review 2022-23 award year of when the 49% exemption or one module in a payment period, and make any R2T4 corrections. Anticipated completion date is May 1, 2023 Contact Lori McDonald at lori.mcclonald@cui.eclu or 949-214-3074

Views of Responsible Officials and Planned Corrective Actions: CSS requires its subrecipients to submit their financial and progress program reports five days after the end of the reporting period. This is done so that CSS can review the underlying documentation in those reports to ensure that proper payments are made to the subrecipients and, in turn, proper and timely reports are filed by CSS with the State of New York. There are instances when, because of delays in receipt of information from the subrecipients, or information from the subrecipients needs to be revised, reports are submitted late to the State of New York. CSS notifies the State of New York when reports will be submitted late. In addition, CSS is working with its subrecipients to improve their reporting procedures, as well as the timeliness and accuracy of their reports. This will result in CSS improving the timeliness of its reporting to the State of New York.

November 17, 2022 To: Chair of the Audit Committee From: Debra Martin, Vice President for Finance and Administration RE: Response to Baker Tilly Audit Communication ? Uniform Guidance Audit Findings Finding 2022-001: Significant Deficiency - Return of Title IV Fund Calculations Program: Student Financial Assistance Cluster Assistance Listing Number (ALN): Various Federal Agency: U.S. Department of Education Federal Award Identification Number: Various Federal Award Year: June 30, 2022 Criteria: 34 CFR 668.22 requires that when a recipient of Title IV grant or loan assistance withdraws from an institution during a payment period or period of enrollment in which the recipient began attendance, the institution must determine the amount of Title IV grant or loan assistance that the student earned as of the student's withdrawal date in accordance with Federal regulations and return the unearned portion of the grant or loan funds to the Title IV programs as soon as possible but no later than 45 days after the withdrawal date. Condition: Two students of five students tested had incorrect/missing calculations. One student was disqualified during the term after the first 8 week session in the Associate Degree of Nursing and could not continue into the second 8 week session. The University did not note the disqualification and withdrawal timely and did not perform an R2T4 calculation as required and the $2,473.53 of direct loans calculated by the auditor was not returned. One student's number of days attended (numerator) was calculated incorrectly at 25 days but should have been 26 days and therefore $59.53 too much Pell was returned. The auditors noted that a total of four students withdrew from the Associate Degree of Nursing program from the population file provided, and two students were not selected by the auditors. The University reviewed these students and noted one student completed more than 60.01% although the auditors learned that the student was disqualified at the end of the first 8 week session and therefore should have had an R2T4 calculation and return, and one student the R2T4 calculation was performed, however the auditor noted the number of days attended (numerator) was calculated incorrectly at 51 days but should have been 52 days and included a negative amount of Pell grant that ?could have been disbursed?. The University noted that an estimated term end date of May 7, 2022 was input in the system and was not updated to the actual term end date of May 6, 2022. As this could impact all students who withdrew during the Spring 2022 term, the auditors noted 21 students in the population file provided who withdrew during spring 2022, and four of those students were noted as withdrawing before 60% and were not tested by the auditors. The University reviewed these students and noted two additional students with incorrect denominators used in their calculations, the auditor reviewed only the denominators for these students and agrees. The sample was not a statistically valid sample. Cause: The University?s controls surrounding completing timely and accurate refund calculations did not operate as designed and resulted in exceptions. Effect: The calculations of funds to be returned to the Department of Education did not occur or were incorrect. Questioned costs: Questioned costs of $2,301.70 (ALN No. 84.268), and $59.53 (ALN No. 84.063) were noted during testing. Context: Exceptions were noted for 2 of the 5 students selected for testing. There were a total of 33 students who withdrew during fiscal year 2022 that received Title IV aid. Recommendation: It is recommended that University personnel review the calculations generated by the University's software system to ensure they are timely and accurate. It is also recommended that the control structure be reviewed to ensure all student who withdraw during a term are identified in a timely manner. Management?s Response: The University will review withdrawal controls and procedures so that students who withdraw are identified and correctly processed in a timely manner. The University will also engage our software system Consultant to examine system settings to ensure accurate and timely Return of Title IV calculations occur. Further, management reviewed and performed the same recalculations for the remaining 28 students in the population. Of those, 24 had no findings or errors and the remaining only had a small amount of excess available Pell funding or loan eligibility. The Pell amounts were awarded and students with loan availability were notified and asked to respond if they wished to borrow the additional funds. All amounts were not material. Correction Action: The Registrar?s Office will provide the Financial Aid Office with final academic calendars in advance to ensure that proper start and end dates of academic periods are correct in the Financial Aid System. Multiple employees (as opposed to a single person) in the Financial Aid office will be tasked with confirming the accuracy of the calendar set-up in advance of the start of each semester. We have also reminded the Nursing department of timely communication of student disqualifications to the Registrar?s office to assist in recognizing students who may fall into this category. In addition to these steps, the University is exploring systematic changes in colleague that will split the ADN and ABSN programs into two separate 8 week sessions with separate start/end dates, as opposed to one 16 week semester that has two sessions within. An RT24 output report will now be automatically generated and reviewed by the Director of Financial Aid every two weeks. Furthermore, the University will apply the same refund calculation policy to ADN students who are academically disqualified, as we do all other student populations. This will ensure accuracy when determining the number days attended and earned amounts of federal aid when processing R2T4 calculations. The University will dedicate additional resources, staff and technology, to manage withdrawal notifications and to process then in a timely manner.

U.S. Department of Education 2022-001 Higher Education Emergency Relief Fund (COVID-19) ? Assistance Listing No. 84.425F Recommendation: We recommend that the University document the individual performing the review, the date of the review, and the conclusion on whether a vendor is suspended or debarred based on performing the appropriate search. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University will make updates to its policies and procedures related to procurement, suspension, and debarment for funds purchased using Federal grant dollars to ensure the documentation of the review of selected vendors for suspension and debarment. Name of the contact person responsible for corrective action: Donald Donovan, Chief Financial Officer Planned completion date for corrective action plan: June 30, 2023