Corrective Action Plans

2022-004 Perkins Promissory Notes - Assistance Listing No. 84.038 Recommendation: We recommend that the College put a procedure in place to ensure that all students have a promissory note prior to disbursing of funds. Also recommend a procedure be put in place to ensure proper record retention documenting the completion of promissory note. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: The process Union College follows to ensure promissory notes are signed is coordinated through Student Financial Services (SFS). SFS determines eligibility of awards and adds them to the student financial package. Once a loan has been accepted SFS has the student sign the promissory note. The loan is disbursed once the paperwork has been completed and reviewed. Perkins loans followed this procedure in the time they were available. The Perkins program is no longer active so there are no new promissory notes going forward. Student accounts is currently reviewing student files to ensure promissory notes or documentation deemed appropriate by the Department of Education is available for the Perkins loans that will be assigned to the Department of Education. The assignment process will be completed by June 30, 2023. The remaining loan files will then be reviewed. Promissory notes or documentation will be retained until the loans are either assigned or liquidated. This review will be completed in FY24. Name(s) of the contact person(s) responsible for corrective action: Brandie Kolff van Oosterwyk, Controller Planned completion date for corrective action plan: FY24.

2022-002 Gramm-Leach-Bliley Act - CFDA No. Various Recommendation: We recommend that the College engage a third party or perform the risk assessment for the three areas required by the Gramm-Leach-Bliley Act and ensure that there are documented safeguards for identified risks. Views of responsible officials: There is no disagreement with the audit finding. Action taken in response to finding: Union College is developing a strategy to comply with the requirements of the Gramm-Leach-Bliley Act. Part of this process involves the consideration of contracting with a consultant to assist with the various aspects of implementing the policies and procedures necessitated by the legislation. We are actively in conversations with CLA regarding this project and are working towards having a substantive plan in place and operational for FY24. Name(s) of the contact person(s) responsible for corrective action: Brandie Kolff van Oosterwyk, Controller Planned completion date for corrective action plan: The goal date for this project to be completed is prior to the FY24 audit.

Management agrees with the recommendation that drawdown requests be reconciled to the general ledger and will implement this in the current fiscal year.

2022-003 Child Nutrition Cluster ? Assistance Listing No. 10.553, 10.555, & 10.559 Recommendation: We recommend the District update policies related to school nutrition reporting to ensure they have appropriate reviews that would prevent or detect errors or fraud. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The School Nutrition Supervisor and Supervisor of Finance approve all expense transactions on an ongoing basis. By the third week of each month, a designated Accounting Assistant runs financial reports used to prepare the monthly school nutrition program claims. The Budget Manager has not approved the claims prior to submission, which has been the practice for all other District programs. Effective July 1, 2022, the accounting assistant schedules a meeting with the School Nutrition Supervisor to review each monthly claim, clarify questions and adjust if needed, prior to submitting a claim to DPI. Name(s) of the contact person(s) responsible for corrective action: Davita Jo Molling, Supervisor of Finance Planned completion date for corrective action plan: July 1, 2022

Finding Number: 2022-005 Condition: The University did not make available timely student HEERF quarterly reporting for the quarter ended September 30, 2021. Planned Corrective Action: Create a review process to ensure correct and timely reporting documents are posted in accordance with federal regulations. Contact person responsible for corrective action: Mark Schroeder, Holly Oswalt Anticipated Completion Date: December 20th, 2022

Finding Number: 2022-004 Condition: Certain credit balances were not refunded to students within 14 days. Planned Corrective Action: Identify one or more additional staff members who can perform this function in the event of illness or absence, cross-train these individuals, and ensure permissions are granted, ensuring appropriate segregation of duties. Contact person responsible for corrective action: Matt Beattie, Mark Schroeder Anticipated Completion Date: February 28, 2023

Finding Number: 2022-003 Condition: The University could not provide records to substantiate that the relevant criteria was complied with by the University in all cases. Planned Corrective Action: Train faculty to preserve and provide documentation related to reported last dates of attendance. This will be stored in the university?s enterprise document management system. Contact person responsible for corrective action: Dina DuBuis, Ann Elinski Anticipated Completion Date: February 15, 2023

Finding Number: 2022-004 Condition: Of the 40 students tested for NSLDS Enrollment Reporting, the University: -For 3 students, reported the status change with incorrect effective dates -For 2 students, reported the status change to NSLDS in an untimely manner Planned corrective Action: The new person hired as the Assistant Registrar for Special Programs and Compliance was officially hired on January 11, 2022. She has gone through training for both NSC and NSLDS. She is and will continue to work closely with Financial Aid related to status change dates and reporting data to the NSLDS. She is responsible for dealing with NSLDS error reports. Contact person responsible for corrective action: Noreen Ferguson, University Registrar Anticipated Completion Date: June 30, 2022. The responsibilities of this position are completed. There will be ongoing training as training sessions become available either through NSC or NSLDS.

2022-002 Significant Deficiency in Internal Controls over Compliance and Compliance - Reporting Agency: U.S. Department of Education Program(s) and Federal Award Identification Number(s): Impact Aid ALN 84.041 FAIN: S041B220137 Contact Person: Ralph Watkins, Superintendent Corrective Action Plan: Documentation issues for Impact Aid application will be resolved in a timely manner. The FY 22 issues have been addressed Completion Date: June 30, 2023

Management?s response: Management agrees with the finding. In January of each year the Fiscal Director, Jerod Nunn, will meet with the grant manager and review the Office of Management and Budget?s compliance supplement. Any changes and/or updates will be noted in the Federal grant files and will be properly followed so the district is in compliance with the Davis-Bacon and Related Acts and Reorganization Plan Regulations.

Finding Number: 2022-001 Condition: Controls in place did not identify an inaccurate calculation of assistance. Planned Corrective Action: The corrective action plan in response to Finding 2021-001 was implemented on September 22, 2022; and therefore the fiscal year ended June 30, 2022 was complete before implementation of the corrective action plan, which is as follows: Case Managers, Quality Review and Agency Managers can see supporting documentation and review cases in real time. All cases are processed by Case Managers, who consult with Agency Managers on questions, and 100 percent of cases are quality reviewed by a team from CLA (an outsourced professional services firm specializing in grants management) prior to processing payment. As Heart of West Michigan United Way receives MSHDA written guidance updates, we continue to hold twice-weekly meetings with CERA Agency Managers to discuss the frequent changes to the MSHDA guidance in order to gain a full understanding of the program requirements and regulations. Information is then disseminated to Case Managers. We will continue to hold regular trainings for CERA Case Managers to ensure consistency in approach and understanding of required documentation and proper assistance calculation. CLA continues to conduct a quality review check of 100 percent of applications to enhance internal controls and oversight. Additionally, the CERA Program Manager completes random checks of assistance calculations and payments. Contact person responsible for corrective action: Gail Montgomery, Vice President of Finance Anticipated Completion Date: September 23, 2022

2022-007 Special Education Cluster (IDEA) and COVID-19 Education Stabilization Fund Recommendation: The School Corporation should implement procedures and controls to ensure all disbursements have proper support and proper approval documented. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The school corporation will strengthen controls to ensure all federal grant expenditures have documentation of review and approval by a person knowledgeable of the grant requirements. Name of the contact person responsible for corrective action: Cheryl Harvey, Business Manager Planned completion date for corrective action plan: Begin immediately

2022-003 Child Nutrition Cluster Recommendation: School Corporation management should establish a system of internal controls to ensure compliance with the grant agreement and program income requirements. Documentation should be retained to support the existence and accuracy of all program income earned. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action planned in response to finding: The school corporation with review existing control processes surrounding program income and strengthen procedures to ensure documentation to support program income is adequate and reviewed. Name of the contact person responsible for corrective action: Cheryl Harvey, Business Manager Planned completion date for corrective action plan: Begin immediately

Need Analysis Planned Corrective Action: PowerFAIDS utilizes the ?Year in School? reported by the student on the ISIR to calculate Federal Direct Loan eligibility during packaging. If misreported by the student, advisors did not always catch these errors in their review. Executive Director of Financial Aid will provide in-house training to all advising staff to ensure proper understanding of awarding and implication of not appropriately updating fields used to calculate aid eligibility. WBU has funded a Financial Aid Compliance Specialist position in the Office of Financial Aid. Once filled, this position with be devoted to internal audit and federal/state regulation compliance. Person Responsible for Corrective Action Plan: Christy Miller, Executive Director of Financial Aid Anticipated Date of Completion: November 2022

The University of New Hampshire respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 01, 2021 to June 30, 2022 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINDINGS?FINANCIAL STATEMENT AUDIT There were no financial statement findings in the current year. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Education 2022-001 Education Stabilization Fund ? Assistance Listing Numbers 84.425E and 84.425F Recommendation: We recommend the Universities and Colleges maintain the documentation used during the reporting process to support the numbers included in the public reporting on their website as well as maintain the formal documentation of the review and approval process that the reports go through during preparation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: The University of New Hampshire (UNH) will work to resolve the reporting finding for fiscal year 2022 reporting. UNH will develop a process to ensure that the information reported is accurate and supporting documentation used to prepare the reports and review and approval of the reports is retained. Name(s) of the contact person(s) responsible for corrective action: Liz Stevens, Director of Student Financial Services (Student Reporting) Susan Zipkin, Director Accounting and Financial Compliance (Institutional Reporting) Planned completion date for corrective action plan: March 31, 2023 If the U.S. Department of Education has questions regarding this plan, please contact the individuals noted above. Plymouth State University respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 01, 2021 to June 30, 2022 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINDINGS?FINANCIAL STATEMENT AUDIT There were no financial statement findings in the current year. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Education 2022-001 Education Stabilization Fund ? Assistance Listing Numbers 84.425E and 84.425F Recommendation: We recommend the Universities and Colleges maintain the documentation used during the reporting process to support the numbers included in the public reporting on their website as well as maintain the formal documentation of the review and approval process that the reports go through during preparation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Plymouth State University (PSU) will work to resolve the reporting finding for fiscal year 2022 reporting. PSU will develop a process to ensure that future information is reported timely, and the review and approval of the reports is documented and retained. The FY21 Uniform Guidance Single Audit was not finalized until June 2022, which contributed to the recurring issues noted in this finding. Name(s) of the contact person(s) responsible for corrective action: Mary Batch, Director of Finance (Institutional Reporting) Mac Broderick, Director of Student Financial Services (Student Reporting) Planned completion date for corrective action plan: July 31, 2022 If the U.S. Department of Education has questions regarding this plan, please contact the individuals noted above. Keene State College respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 01, 2021 to June 30, 2022 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINDINGS?FINANCIAL STATEMENT AUDIT There were no financial statement findings in the current year. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Education 2022-001 Education Stabilization Fund ? Assistance Listing Numbers 84.425E and 84.425F Recommendation: We recommend the Universities and Colleges maintain the documentation used during the reporting process to support the numbers included in the public reporting on their website as well as maintain the formal documentation of the review and approval process that the reports go through during preparation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Keene State College (KSC) will work to resolve the reporting finding for fiscal year 2022 reporting. KSC developed a process to ensure that the information is reporting timely, accurately, and supporting documentation used to prepare the reports and review and approval of the reports is retained. The FY21 Uniform Guidance Single Audit was not finalized until June 2022, which contributed to the recurring issues noted in this finding. Name(s) of the contact person(s) responsible for corrective action: Catherine Mullins Planned completion date for corrective action plan: July 1, 2022 If the U.S. Department of Education has questions regarding this plan, please contact the individuals noted above. Granite State College respectfully submits the following corrective action plan for the year ended June 30, 2022. Audit period: July 01, 2021 to June 30, 2022 The finding from the schedule of findings and questioned costs is discussed below. The finding is numbered consistently with the numbers assigned in the schedule. FINDINGS?FINANCIAL STATEMENT AUDIT There were no financial statement findings in the current year. FINDINGS?FEDERAL AWARD PROGRAMS AUDITS U.S. Department of Education 2022-001 Education Stabilization Fund ? Assistance Listing Numbers 84.425E and 84.425F Recommendation: We recommend the Universities and Colleges maintain the documentation used during the reporting process to support the numbers included in the public reporting on their website as well as maintain the formal documentation of the review and approval process that the reports go through during preparation. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Granite State College (GSC) will work to resolve the reporting finding for fiscal year 2022 reporting. GSC and the University of New Hampshire (UNH) are in the process of merging as part of a new college within UNH, which resulted in a transition of reporting responsibilities and processes. GSC and UNH will develop a process to ensure that the information reported is accurate and supporting documentation for the review and approval of reports is retained. The FY21 Uniform Guidance Single Audit was not finalized until June 2022, which contributed to the recurring issues noted in this finding. Name(s) of the contact person(s) responsible for corrective action: Andrea Nepveu, Acting Director of Financial Aid (Student Reporting) Susan Zipkin, Director, Accounting and Financial Compliance (Institutional Reporting) Planned completion date for corrective action plan: March 31, 2023 If the U.S. Department of Education has questions regarding this plan, please contact the individuals noted above.

TOFMHS will implement a Preparer of the SF 425 wherein the reports will be ?Prepared? by the Fiscal Officer, and ?Certified? by the Program Director, who will have that role in PMS (Payment Management System).

SIGNIFICANT DEFICIENCY IN INTERNAL CONTROL OVER COMPLIANCE ? U.S. DEPARTMENT OF THE TREASURY, PASSED THROUGH MINNESOTA DEPARTMENT OF EDUCATION AND INDEPENDENT SCHOOL DISTRICT NO. 270, HOPKINS, COVID-19 ? CORONAVIRUS STATE AND LOCAL FISCAL RECOVERY FUNDS ? FEDERAL ALN 21.027 2022-003 Internal Control Over Compliance With Federal Suspension and Debarment Requirements Finding Summary 2 CFR ? 180 requires Independent School District No. 283 (the District) to establish and maintain effective internal control over compliance with requirements applicable to federal program expenditures, including suspension and debarment requirements. The District did not have sufficient controls in place within its COVID-19 ? Coronavirus State and Local Fiscal Recovery Funds federal programs to assure that it was not contracting for goods or services with parties that are suspended or debarred, or whose principals are suspended or debarred from participating in contracts involving the expenditures of federal program funds. Corrective Action Plan Actions Planned ? The District will review policies and procedures relating to suspension and debarment for its federal programs and will ensure that all parties with which it contracts for goods or services are eligible to participate in contracts involving the expenditures of federal program funding. Official Responsible ? Patricia Magnuson, Director of Business Services. Planned Completion Date ? June 30, 2023. Disagreement With or Explanation of Finding ? The District agrees with this finding. Plan to Monitor ? Patricia Magnuson, Director of Business Services, will assure appropriate controls are in place, and will review internal control procedures relating to suspension and debarment to ensure they are in line with the Uniform Guidance requirements.

2022-005 Higher Education Emergency Relief Funds (HEERF) Reporting Award Period: July 1, 2021 to June 30, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance; Other Matters Recommendation: We recommend the College establish controls to ensure accurate and timely reporting. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Tabor College will ensure proper documentation of reviews for reporting and that report submission guidelines are followed. Name(s) of the contact person(s) responsible for corrective action: Cathy Castle, Vice President for Business and Finance Planned completion date for corrective action plan: Immediately as additional federal awards are received.

2022-007 Gramm-Leach-Bliley Act Award Period: July 1, 2021 to June 30, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance; Other Matters Recommendation: We recommend that the College engage a third party or perform the risk assessment for the three areas required by the Gramm-Leach-Bliley Act and ensure that there are documented safeguards for identified risks. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Tabor College is currently meeting with companies who provide services to assist with meeting the requirements of the Gramm-Leach-Bliley Act. Name(s) of the contact person(s) responsible for corrective action: Cathy Castle, Vice President for Business and Finance Planned completion date for corrective action plan: April 2023 and ongoing. If the Department of Education has questions regarding this plan, please call Cathy Castle at 620-947-3121 x 1056.

2022-004 National Student Loan Data System (NSLDS) Award Period: July 1, 2021 to June 30, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance; Other Matters Recommendation: We recommend the College review its reporting procedures to ensure the 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: Tabor College utilizes a clearing house for submitting student statuses. Tabor will ensure that all students statuses are filed accurately and timely. Name(s) of the contact person(s) responsible for corrective action: Scott Franz, Interim Financial Aid Director Planned completion date for corrective action plan: April 2023

2022-003 Return of Title IV (R2T4) Award Period: July 1, 2021 to June 30, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance; Other Matters Recommendation: We recommend the College review the return of Title IV funds requirements and implement procedures to ensure the return of Title IV funds calculations are using the correct number of break days and are accurately completed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Tabor College will ensure the correct number days are used in all R2T4 calculations, including times when there are break days during the school term. Name(s) of the contact person(s) responsible for corrective action: Scott Franz, Interim Financial Aid Director Planned completion date for corrective action plan: This has begun with the 2022-23 school term

2022-002 Eligibility and Certification Approval Report (ECAR) Award Period: July 1, 2021 to June 30, 2022 Type of Finding: Significant Deficiency in Internal Control over Compliance; Other Matters Recommendation: We recommend the College review its reporting procedures surrounding updating the ECAR to ensure reporting is accurate and completed. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Tabor College will ensure that ECAR is updated in a timely manner when there is a change in a position of an official for the institution. Name(s) of the contact person(s) responsible for corrective action: Scott Franz, Interim Financial Aid Director Planned completion date for corrective action plan: April 2, 2023

Finding 2022-001 Significant Deficiency Federal Program: HOME Investment Partnerships program Assistance Listing Number: 14.239 Federal Grantor: Department of Housing and Urban Development Federal Award Year: 2021-2022 Management?s Response and Corrective Actions: Background: Since 1985, the City of Inglewood has approximately 90 loans issued to homeowners under the HOME Program for either homebuyer programs or for housing rehabilitation programs. Over the years, the City has contracted with the outside agency, Inglewood Neighborhood Housing Services (INHS) to administer these homeowner loan programs for Inglewood residents. Additionally, the City has directed the Community Development Block Grant (CDBG) Division and the former Inglewood Redevelopment Agency to oversee the administration of these loans. It has been demonstrated that the now defunct INHS has issued loans to homeowners and may not have recorded each transaction accurately, thus resulting in some loans being paid off without proper noticing to the City. Some homeowner loans were not adequately identified as being loans attributable to the City; and some loans issued were misidentified as being either City loans from the U.S. Department of Housing and Urban Development (HUD) or City loans from the former State of California Department of Finance Redevelopment Agency (RDA). In 2007, the City has retrieved the loan files from INHS in an attempt to reconcile the outstanding loans issued by INHS, with those loans already repaid or otherwise closed. The City?s CDBG Division along with the RDA has been tasked with reconciling the home loans for both HUD and the RDA. During this period, the City suffered a gradual reduction in HUD CDBG and HOME funds which resulted in the gradual reduction of key CDBG staff members, beginning with the separation of the Senior Grants Coordinator, the Grants Coordinator, the CDBG Division Accountant, and the CDBG Administrative Analyst. The remaining full-time staff and two new full-time CDBG Division staff saw the retirement of the Grants Manager, and a series of five subsequent managers since 2013. In a drastic turn of events and after a long litigation at the State level, effective February 1, 2012, California experienced the dissolution of over 400 of the state?s RDAs, including the City?s RDA, a once robust agency with over 15 staff members. At the local level, the City of Inglewood was named as the Successor Agency responsible to manage Inglewood redevelopment projects currently underway, make payments on enforceable obligations, and dispose of redevelopment assets and properties. With the dissolution of the Inglewood RDA, staffing was reduced to five remaining members. As of 2016, the Successor Agency had only two staff members, one full-time staff member and one part-time staff-member. Unfortunately, with the high level of turnover in the City, the City loans were not consistently updated in a timely fashion. Since 2019, the City has stabilized its staffing to include a HUD Programs Manager who is responsible for overseeing the Home Loan Programs. The HUD Programs Manager will ensure the loans are properly monitored and serviced. The City has two Senior Program Specialists who have a combined total of over 40 years of experience in HUD Programs. The City is currently recruiting for a third Senior Program Specialist. Corrective Action 1.0: The City will review each loan on the outstanding loan schedule and will update each to ensure the status is correct according to the schedule. For any outstanding loan where the terms have been satisfied, the City will ensure these are properly recorded as receivable and listed on the HOME loan receivable schedule maintained by the City. Projected Time of Completion: Each loan is scheduled to be updated by December 30, 2023. Corrective Action 2.0: The City will reconcile its records to ensure the each City loan is accounted for according to the source of funding and the terms of each loan. Staff will ensure each loan is properly recorded with the Los Angeles County Recorder?s Office, if required. Projected Time of Completion: April 30, 2024 Corrective Action 3.0: Staff will implement an intense cross-training session amongst the Finance Department Accounting Division, the Successor Agency, and the CDBG Division to ensure that all responsible staff are thoroughly trained to service and monitor the Home Program Loan files. Corrective Action 3.1: Staff will update the HOME Procedures Manual (Manual) to include the cross-training policy and any other program updates, as appropriate, to current procedures and protocol. The Manual will be maintained in a shared file for reference by all staff and willl be made available to the public upon request. Projected Time of Completion: April 30, 2024 Corrective Action 4.0 (1) Staff will monitor, annually, the outstanding loan files and will service and update the loan files as requests are made to the City. (2) Staff will notify the Accounting Division when a loan changes status and provide the appropriate supporting documentation, immediately upon receipt. (3) The HUD Programs Manager will ensure the loan files and all transactions are maintained in a shared file. (4) The HUD Programs Manager will assign staff to report quarterly on any changes to the loan files. Projected Time of Completion: Quarterly, at a minimum.

U.S. Department of Health and Human Services 2022-002 Provider Relief Fund ? Assistance Listing No. 93.498 Recommendation: Management should implement procedures to ensure the lost revenue is calculated and reported using an option that is appropriate for any future periods and revise the lost revenue amounts on any subsequent filings, if applicable. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management will design and implement procedures of review ensuring the appropriate option is selected for how lost revenue is reported for any future reporting periods and on any subsequent filings. Name(s) of the contact person(s) responsible for corrective action: Beau Brown, CFO Planned completion date for corrective action plan: September 30, 2023.

U.S. Department of Health and Human Services 2022-001 Health Center Program Cluster? Assistance Listing No. 93.224 & 93.527 Recommendation: Management should review their policies and procedures with the personnel responsible for providing the sliding fee discount. We also recommend that management implement, monthly or quarterly, a self-audit process of newly approved sliding fee discount applicants and their associated patient record. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: Management has designed and implemented continuous training regarding the sliding fee discount program policies and procedures, and monthly internal audit reviews of approved sliding fee discount applicants and their associated patient record. Name(s) of the contact person(s) responsible for corrective action: Beau Brown, CFO Planned completion date for corrective action plan: September 30, 2023.